Application Form | Yellow Fever Vaccine Exemption Certificate - wilmerhealth.com

Application Form | Yellow Fever Vaccine Exemption Certificate

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Your Details

Name *

First

Last

Mobile Number *

Email *

Your certificate will be sent to this email address

Sex *

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

About Your Exemption

Are you over the age of 60? *

Yes
No

Is being over 60 the reason you are applying for an exemption certificate? *

Yes
No

Please explain why you believe you are exempt from receiving the yellow fever vaccine: *

Medical History

Do you have any medical conditions that may prevent you from safely receiving the vaccine? *

Yes
No

If yes, please give us further details about your medical conditions here: *

Do you currently take any medications? *

Yes
No

If yes, please list the medications you take here: *

Are you affected by any of the following? (you can select more than one option) *

I am not affected by any of these conditions
An allergy to a component of the vaccine.
A history of severe allergic reactions (anaphylaxis) to the vaccine.
A weakened immune system (e.g. due to lymphoma, leukemia, or other causes).
Taking immune-suppressing medications (e.g. chemotherapy, steroids).
A thymus gland disorder or history of thymus removal.
Myocarditis or pericarditis following COVID-19 vaccination.
A close relative who experienced severe vaccine-related complications, such as brain or organ damage.
A history of multisystem inflammatory syndrome.
Severe learning disabilities or autism that would cause significant distress with vaccination.
A terminal illness

Identity Verification

Please upload an IMAGE of a form of photographic ID to verify your identity (e.g. passport, driving licence). *

Click or drag files to this area to upload. You can upload up to 100 files.

Evidence of Exemption Criteria

Please upload proof of your exemption (e.g. a digital summary care record from your online medical record or any other official documentation). *

Click or drag files to this area to upload. You can upload up to 10 files.

Anything Else? (Optional)

Is there anything else you'd like to add before submitting your application? Please include it here:

Terms and Conditions

By submitting your application, you acknowledge that you have read and agree to our Terms and Privacy Policy, and you consent to the following:

You understand the potential health risks of remaining unvaccinated against this disease and accept full responsibility for your decision.
You confirm that all the information provided in the medical questionnaire has been understood and answered truthfully to the best of your knowledge.
The certificate or letter requested is specifically for the individual named in the application, based on the details provided.
The issued certificate confirms that you have a medical reason for being unable to receive the vaccine, based on available medical evidence. It is not an insurance policy, guarantee, or medical indemnity and does not serve as a recommendation to avoid vaccination.
Wilmer Health is not a replacement for a physical doctor’s consultation. The healthcare professionals at Wilmer Health may not have access to your NHS or GP medical records, nor do they act as your primary care provider.
Once our doctor has reviewed your request and a certificate has been issued, Wilmer Health is unable to offer refunds.
If an employer, institution, or other third party rejects your Wilmer Health certificate, neither Wilmer Health nor its doctors can be held responsible for any resulting costs or consequences.
You agree to release both Wilmer Health and its doctors from any liability related to adverse events affecting you or others at any time.
You agree to update your primary doctor or GP regarding your medical condition and exemption from receiving the vaccine.

Agreement to Terms and Conditions *

I have read and agree to the Terms and Conditions listed above

Checkout

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Yellow Fever Vaccine Exemption Certificate

Price: £45.00