Parent's Full Name
First Name
Last Name
Infant’s Name
First Name
Last Name
Infant’s Date of Birth
-
Month
-
Day
Year
Date
Medical Risk Factors
Please Select
Infant born prematurely
Recent NICU discharge
Chronic respiratory/immune condition
Household member immunocompromised
Born during RSV/flu season
Exposure Risks
Please Select
Air travel or crowded public spaces
Wildfire smoke or poor air quality
Pediatrician recommended extra protection
Confirmation Checkbox
“I confirm the above information is true and understand this letter is for insurance reimbursement purposes only.”
Submit
Should be Empty: