COVID-19 Determination of Extreme ... - Miami-Dade County

COVID-19 Determination of Extreme Vulnerability

Physician Name:__________________________________________________________________________________________

Last/Surname

First

Middle

Physician License Number: _______________________ Physician Telephone Number: ____________________ Physician Practice Address: ______________________________________________________________________ Physician Email Address:__________________________________

Patient Name: __________________________________________________________________________________________

Last/Surname

First

Middle

Patient Date of Birth: ________________________________

Patient Address: ________________________________________________________________________

City: _________________________ State: ______________ ZIP Code: _______________________

Patient Telephone Number: ________________________________________

CERTIFICATION OF PATIENT'S EXTREME VULNERABILITY TO COVID-19

I hereby certify that I have a physician-patient relationship with the patient named above and that I have determined that the patient is extremely vulnerable to COVID-19 for the purposes of receiving a COVID-19 vaccination in the state of Florida.

I attest that I am the physician listed above and the statements in this determination are true and complete.

Physician's Signature: ___________________________________________________ Date: ___________

MM/DD/YYYY

DH8014-DCHP-03/2021, 64DER21-3

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