Immunization Recall Exclusion

Please complete this form in its entirety. Contact the North Dakota Department of Health (NDDOH) Immunization Program at 701.328.3386 or 800.472.2180 if you have questions.

Name of individual to be excluded from immunization reminder and recall:
 
Birthdate of individual to be excluded:
  
Name of person requesting the exclusion:
 
Relationship to individual to be excluded:
 
Any comments