Form Refusal To Vaccinate printable pdf download

The Pediatric Center of Stone Mountain, LLC

Form_Refusal_to_Vaccinate.docx

Patient Name _______________________________DOB_______________

I am choosing to refuse ALL recommended vaccines for my child.

I am aware the these vaccines are required for entry to Georgia schools.

I understand that this document serves as notification that I am refusing to vaccinate

my child at this visit and all future visits at The Pediatric Center of Stone Mountain.

I may terminate this refusal at anytime by signing a Consent to Vaccinate Form.

POLIO: Refuse _______

RUBEOLA (MEASLES): Refuse _________

HEMOPHILUS INFLUENZAE B Refuse __________

MUMPS: Refuse ___________

PERTUSSIS Refuse _________

RUBELLA (GERMAN MEASLES): Refuse

_____________

DIPTHERIA: Refuse ___________

HEPATITIS B: Refuse __________

TETANUS (LOCKJAW) Refuse __________

VARICELLA (CHICKENPOX): Refuse _________

I understand that by refusing the vaccines Refused above, I am acting against the recommendations

of my child(ren)'s physician(s) and am placing my child(ren) at risk for developing the conditions

described above. I understand that The Pediatric Center of Stone Mountain, LLC. or any of its

employees or physicians are not legally responsible for any claims or expenses that may happen

should any of my child(ren) contract (get sick) from one or more of the above illnesses.

By signing this statement, I am stating that I understand that the above illnesses can safely be

prevented by commonly administered immunizations and that I, of my own free will and with full

disclosure, am acting against the recommendations of The Pediatric Center of Stone Mountain, LLC.

and/or its employees by refusing the immunizations listed above for my child(ren).

I have received written and verbal information about each of the conditions listed above and have

had several opportunities to have my questions answered by my child(ren)'s physician.

Printed Name & Relationship of the Primary Caregiver: _____________________________

Signature (Primary Caregiver) _______________________________Date____________

Printed Name & Relationship of 2nd Primary Caregiver: _____________________________

Signature (2nd Primary Caregiver)________________________________Date____________

03/27/2013

Form Refusal To Vaccinate