Refusal To Consent To Vaccination Form (Children And Adolescents)


Refusal to Consent to Vaccination
Children and Adolescents
This tool is used to document a refusal to vaccinate in the patient’s medical record. This is not a waiver form. Parents or guardians
may obtain a form for a waiver from the child’s childcare or school program. Contact your local health department for more
information. Remember to document vaccine refusal in the Michigan Care Improvement Registry.
Child’s Name:
Child’s ID#
Parent’s/Guardian’s Name(s):
My child’s health care provider,
, has advised me that my child (named above) should receive the
following vaccines:
Reason for Refusal
Diphtheria, tetanus, acellular pertussis (DTaP)
Diphtheria, tetanus (DT or Td)
Haemophilus influenzae type B (Hib)
Hepatitis A (Hep A)
Hepatitis B (Hep B)
Human papillomavirus (HPV)
Measles, mumps, rubella (MMR)
Meningococcal (MCV or MPSV)
Pneumococcal vaccine (PCV or PPSV)
Polio (IPV)
Rotavirus (RV)
Tetanus, diphtheria, acellular pertussis (Tdap)
Varicella (chickenpox) (Var)
I have read the Centers for Disease Control and Prevention’s Vaccine Information Statement(s) explaining the vaccine(s) and the
disease(s) they prevent. My child’s health care provider has explained to me (and I understand) the following:
The purpose of the recommended vaccination
The risks and benefits of the recommended vaccination
Possible consequence(s) of not allowing my child to receive the recommended vaccination may include contracting the
illness the vaccine is intended to prevent and transmitting the disease to others
My doctor, the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease
Control and Prevention, and the Michigan Department of Community Health strongly recommend that the vaccine(s)
be given.
The health care provider has answered all of my questions.
I know that I may change my mind and accept vaccination for my child in the future.
I accept sole responsibility for any consequences as a result of my child not being vaccinated.
I acknowledge that I have read this document in its entirety and fully understand it.
Parent/Guardian Signature
I have had the opportunity to re-discuss my decision not to vaccinate my child and still decline the recommended immunizations:
Parent’s initials_______ Date________ Parent’s initials_______ Date________ Parent’s initials_______ Date________
Parent’s initials_______ Date________ Parent’s initials_______ Date________ Parent’s initials_______ Date________
Rev 3/2014
Adapted from the American Academy of Pediatrics (AAP)


51 votes

Related Articles

Related forms

Related Categories

Parent category: Medical