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.

Required Immunization Dates

Most recent within the past 10 years

First dose of immunization

Second dose of immunization

Recommended Immunization Dates

Doctor of Physical Therapy Students ONLY

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).