Hospital Letter Head Blank Form PDF Details

Are you running a business in the healthcare industry and are looking for an easy way to create professional letterhead? If so, then having access to a hospital letter head blank form can be immensely beneficial. Not only will it save time by providing pre-made formats that make creating customized documents simpler, but it can also help you maintain a high level of professionalism when communicating with clients or customers. In this blog post, we’ll explore why having your own customizable hospital letter head is important and how its use can help add an air of authority to any document you produce.

QuestionAnswer
Form NameHospital Letter Head Blank Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesjefferson county al letterhead pdf, jefferson letterhead template, thomas hospital letterhead, jefferson hospital letterhead template

Form Preview Example

University Health Services

T 215.955.6835 F 215.923.5778

jeffuhs@jeffersonhospital.org

STATEMENT OF EXEMPTION TO COLLEGE AND UNIVERSITY STUDENT VACCINATION ACT

Student’s name _______________________________________ Date of Birth ______________

Parent or Guardian name (if under 18) ____________________________________________________

Address ____________________________________________________________________________

Telephone ( ) _____________________

I have been given a copy and have read, or have had explained to me, the information in the Meningococcal Vaccine Information Statement for meningococcal disease. I have had a chance to ask questions that were answered to my satisfaction. I believe that I understand the benefits and risks of the vaccine required. However, I am requesting exemption from Senate Bill No. 955, the College and University Student Vaccination Act.

Medical Exemption

The physical condition of the above named student is such that immunization would endanger life or health.

Signed _____________________________________________

Date __________________

(Physician signature required)

 

Religious or Other Exemption

I, ______________________________________, adhere to a religious belief or have another belief

(printed name)

that is opposed to such immunizations. State your reason for requesting a religious or other exemption.

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Signed _____________________________________________

Date ___________________

(Student signature or Parent/Guardian signature)

 

Please return this form to:

Attention: Student Coordinator

 

University Health Services

Thomas Jefferson University Hospital

833 Chestnut Street, Suite 205

Philadelphia, PA 19107

833 Chestnut Street, Suite 205, Philadelphia, PA 19107

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Writing segment 1 in thomas jefferson letterhead

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Attention Student Coordinator, Date, and Chestnut Street Suite inside thomas jefferson letterhead

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