Medical Exemption Denials 
As part of our legislative advocacy efforts, Health Action MA is collecting medical exemption denial testimonies for children/teens, by medical professionals in Massachusetts. 

Whether for a vaccine injury, family history or condition, please complete the form below. 

Information submitted in this form will not be shared publicly or with any third parties. 

Thank you 

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Email *
First Name *
Last name *
Town *
Zip Code  *
Phone Number
Who is filling out this form *
Reason for medical exemption *
If 'other' please detail 
Was the exemption needed for school or services (such as Early Intervention).  *
Was the medical provider located in Massachusetts  *
If the medical exemption request was due to a vaccine adverse event, was the injury documented? *
If the medical exemption request was due to a vaccine adverse event, was it 
Reasons given for exemption denial  *
If 'other' please detail 
Please provide a brief description of the exemption denial  *
Future Communications: Do you consent to future communications from Health Action MA regarding legislative action/updates for medical exemption denials. *
I would like to testify (written and/or verbally) before the legislature regarding my exemption denial. Please note: this will be public record.  *
A copy of your responses will be emailed to the address you provided.
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