Refusal To Consent To Vaccination Form (Children And Adolescents) printable pdf download

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:

Recommended

Vaccine

Declined

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)

Influenza

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)

Other:_______________________________

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

Date

Witness

Date

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________

Rev 3/2014

Adapted from the American Academy of Pediatrics (AAP)

Refusal To Consent To Vaccination Form (Children And Adolescents)

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