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    Refusal To Vaccinate Form

    Uploaded by

    blcksource
    A template to use in opting out of vaccines.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Refusal To Vaccinate Form

    Uploaded by

    blcksource
    274 views1 page
    A template to use in opting out of vaccines.

    Original Title

    Refusal to Vaccinate Form

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

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    A template to use in opting out of vaccines.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    274 views1 page

    Refusal To Vaccinate Form

    Uploaded by

    blcksource
    A template to use in opting out of vaccines.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Refusal to Vaccinate

    Childs Name

    Childs ID#

    Parents/Guardians Name
    My childs doctor/nurse,
    has advised me that my child (named above) should receive the
    following vaccines:
    Recommended

    Declined

    Hepatitis B vaccine

    Diphtheria, tetanus, acellular pertussis

    That some vaccine-preventable diseases are common in other


    countries and that my unvaccinated child could easily get one
    of these diseases while traveling or from a traveler.

    If my child does not receive the vaccine(s) according to the


    medically accepted schedule, the consequences may include
    Contracting the illness the vaccine is designed to prevent
    (the outcomes of these illnesses may include one or more
    of the following: certain types of cancer, pneumonia, illness
    requiring hospitalization, death, brain damage, paralysis,
    meningitis, seizures, and deafness; other severe and
    permanent effects from these vaccine-preventable
    diseases are possible as well).
    Transmitting the disease to others (including those too young
    to be vaccinated or those with immune problems), possibly
    requiring my child to stay out of child care or school and
    requiring someone to miss work to stay home with my child
    during disease outbreaks.

    My childs doctor and the American Academy of Pediatrics, the


    American Academy of Family Physicians, and the Centers for
    Disease Control and Prevention all strongly recommend that
    the vaccine(s) be given according to recommendations.

    (DTaP or Tdap) vaccine

    Diphtheria tetanus (DT or Td) vaccine

    Haemophilus influenzae type b (Hib) vaccine

    Pneumococcal conjugate or polysaccharide vaccine

    Inactivated poliovirus (IPV) vaccine

    Measles-mumps-rubella (MMR) vaccine

    Varicella (chickenpox) vaccine

    Influenza (flu) vaccine

    Meningococcal conjugate or polysaccharide vaccine

    Hepatitis A vaccine

    Rotavirus vaccine

    Human papillomavirus vaccine

    Other

    I have been provided with and given the opportunity to read


    each Vaccine Information Statement from the Centers for Disease
    Control and Prevention explaining the vaccine(s) and the disease(s)
    it prevents for each of the vaccine(s) checked as recommended and
    which I have declined, as indicated above. I have had the opportunity
    to discuss the recommendation and my refusal with my childs doctor
    or nurse, who has answered all of my questions about the recommended vaccine(s). A list of reasons for vaccinating, possible health
    consequences of non-vaccination, and possible side effects of each
    vaccine is available at www.cdc.gov/vaccines/pubs/vis/default.htm.
    I understand the following:

    The purpose of and the need for the recommended vaccine(s).

    The risks and benefits of the recommended vaccine(s).

    Nevertheless, I have decided at this time to decline or defer the


    vaccine(s) recommended for my child, as indicated above, by checking the appropriate box under the column titled Declined. I know
    that failure to follow the recommendations about vaccination may
    endanger the health or life of my child and others with whom my
    child might come into contact. I therefore agree to tell all health
    care professionals in all settings what vaccines my child has not
    received because he or she may need to be isolated or may require
    immediate medical evaluation and tests that might not be
    necessary if my child had been vaccinated.
    I know that I may readdress this issue with my childs doctor or nurse
    at any time and that I may change my mind and accept vaccination
    for my child any time in the future.
    I acknowledge that I have read this document in its entirety and fully
    understand it.

    Parent/Guardian Signature:

    Date:

    Witness:

    Date:

    I have had the opportunity to rediscuss my decision not to vaccinate my child and still decline the recommended immunizations.
    Parents Initials:

    Copyright 2013

    Date:

    9-80/Rev0912

    Parents Initials:

    Date:

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