REQUEST FOR MEDICAL EXEMPTION
This portion must be completed by a licensed physician or optometrist when a certificate of exemption is requested due to a physical condition. NOTE: The exemption is valid only for colorless sun screening products that filter ultraviolet rays.
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PATIENT INFORMATION
Patient Name ___________________________________________ Daytime Telephone # _________________
Street Address _____________________________________________________________________________
City ___________________________________________________ State __________ Zip Code ___________
Brief Description of patients condition: ___________________________________________________________
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Suggested Treatment(s): _____________________________________________________________________
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PHYSICIAN/OPTOMETRIST INFORMATION
Physician/Optometrist Name ___________________________________________________
Business Affiliation (if any) _____________________________________________________
Business Address ____________________________________________________________
City ___________________________________________ State _____ Zip Code _________
Physician Telephone Number __________________________________________________
I certify under penalty of law that the above facts are true and correct to the best of my knowledge:
Signature _______________________________________ Date _____________________