Raising Sages Integrative Pediatrics Refusal To Vaccinate Form printable pdf download

RAISING SAGES INTEGRATIVE PEDIATRICS

REFUSAL TO VACCINATE FORM

Childs Name and DOB

_______________________________________

Parent’s Name (Printed clearly)

__________________________________

My child’s physician(s) and/or staff have discussed the recommendations of the

CDC/ACIP vaccine schedule with me and have informed me of the relative pros and cons of

the routine schedule. They have stated clearly that it is the consensus and recommendation

of the American Academy of Pediatrics and the CDC that all children should be vaccinated

according to this schedule. I have been provided with access to the CDC’s Vaccine

Information Statements (VIS) and I have had the opportunity to review them before, during or

after my discussion with my child’s doctor. I am aware that while there are certain risks of side

effects involved with vaccinations, there are also risks involved by not vaccinating my child,

including: catching the disease which the vaccine is meant to prevent, including all potential

complications and serious effects of the disease and transmitting the disease to others who

are either too young or are unable (for medical reasons) to receive the vaccination.

Nevertheless, our family has decided to defer some or all of the recommended

vaccines at this time. I realize that my doctor will gladly continue to care for my family and

accepts our ultimate decision as to what we feel is best for our child at this time. I also realize

that I may change my mind at any time in the future and redress the question as needed. I

also agree that if I suspect my child has obtained a potentially vaccine-preventable disease, I

will inform my physician promptly so that we may be evaluated and treated appropriately, as

well as taking the proper infection control precautions when coming to the office as to the

lessen the risk of potentially infecting other vulnerable patients.

I understand that the following vaccines are indicated at my child’s age, and that I am

declining them for my child at this time:

VACCINE

RECOMMENDED

DECLINED

By CDC/ACIP

Hepatitis B

DTaP/Tdap

Hib (Haemophilus influenzae type b)

PCV-13 (Pneumococcal)

Polio (Inactivated)

MMR (Measles/Mumps/Rubella)

Varicella/ Chickenpox

Influenza

Meningococcal

Hepatitis A

Rotavirus

HPV (Human Papillomavirus)

I acknowledge that I have read this document in its entirety and fully understand it,

and that I have no further questions regarding this issue to discuss with my physician at this

time.

Parent Signature:

_____________________________________________________

Date:

_____________________________________________________

Raising Sages Integrative Pediatrics Refusal To Vaccinate Form

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