Refusal To Receive Vaccination printable pdf download

Refusal To Receive Vaccination

Refusal to Receive Vaccination

Patient’s Name:

____________________________ Patient’s ID # ___________________________

My health care provider, ________________________________________ has advised me that I should

receive the following vaccines:

Recommended

Refused

Influenza (flu) Vaccine

Pneumococcal Polysaccharide Vaccine (PPV23)

I understand:

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

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

My health care provider, the Advisory Committee on Immunization Practices, the

Centers for Disease Control and Prevention, and the New York City Department of Health

and Mental Hygiene all strongly recommend that the vaccine(s) be given.

< If I do not receive the vaccine(s), the consequences may include increased risk of:

Getting sick from the illness the vaccine could prevent

Spreading the disease to others who could become ill, be hospitalized,

or die as a result.

Being hospitalized for heart disease, stroke, pneumonia, or influenza, if I am 65

years of age or older.

Death, if I am 65 years of age or older.

Nevertheless, I have decided to refuse the vaccine(s) recommended above by checking the appropriate

box under the column titled “Refused”.

I know that my failure to follow these recommendations for vaccination may endanger my health or the

health of people I come in contact with.

I know that, even though I refuse to be vaccinated now, I can change my mind at any time and accept

vaccination in the future.

I acknowledge that I have read this refusal form in its entirety and fully understand it.

Signature _____________________________ Date: ____________

Witness: ______________________________ Date: ____________

Refusal To Receive Vaccination