Immunization Information Form Fields marked with a * are required. Please enter the appropriate dates for your immunization information. If you have a Medical Exemption or Conscientious Exemption please download the Medical Exemption Form, complete, and mail or fax (651.603.6320) it back to the Admission Office. Student ID * Email * First Name * Last Name * Middle Initial Required Immunization Dates DT (Diphtheria-Tetanus) * Most recent within the past 10 years MMR - 1 (Measles, Mumps, Rubella) * First dose of immunization MMR - 2 (Measles, Mumps, Rubella) * Second dose of immunization Recommended Immunization Dates Hepatitis B - 1 Hepatitis B - 2 Hepatitis B - 3 Menactra Varicella - 1 Varicella - 2 HPV - 1 (Human Papillomavirus) HPV - 2 (Human Papillomavirus) HPV - 3 (Human Papillomavirus) Hepatitis A - 1 Hepatitis A - 2 Doctor of Physical Therapy Students ONLY Influenza Polio Pneumococcal Tetanus-diphtheria-acellular pertussis Tuberculosis Form Submission By submitting this form, I certify that the above dates are accurate information and that I have received the immunizations required by Minnesota State Law (M.S. 135A. 14).