Refusal To Consent To Vaccination (Adult)

ADVERTISEMENT

Refusal to Consent to Vaccination (Adult)
This is a tool for office practices to use for documentation in the patient’s medical record. This is not a waiver form.
Contact your local health department for more information. Remember to document vaccine refusal in the Michigan Care
Improvement Registry.
Name:
ID#
My health care provider, ________________________________ , has advised me that I should receive the following
vaccines:
Recommended
Vaccine
Declined
Reason for Refusal
Hepatitis B (Hep B)
Hepatitis A (Hep A)
Tetanus, diphtheria (Td)
Tetanus, diphtheria, acellular pertussis (Tdap)
Pneumococcal (PPSV or PCV)
Influenza, Seasonal
Measles, mumps, rubella (MMR)
Varicella (Var)
Human papillomavirus (HPV)
Meningococcal (MCV, MPSV)
Zoster (shingles) (HZV)
Other:
I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Statement(s) explaining the
vaccine(s) and the disease(s) they prevent. My 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 receiving the recommended vaccination may include contracting the illness
the vaccine is intended to prevent and transmitting the disease to others
My doctor, the American College of Obstetricians and Gynecologists, 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 in the future.
I accept sole responsibility for any consequences as a result of not being vaccinated.
I acknowledge that I have read this document in its entirety and fully understand it.
Signature
Date
Time
Witness
Date
Time
I have had the opportunity to re-discuss my decision not to be vaccinated and still decline the recommended immunizations:
Initials_______________ Date/Time_______________ Initials_______________ Date/Time_______________
Initials_______________ Date/Time_______________ Initials_______________ Date/Time_______________
Initials_______________ Date/Time_______________ Initials_______________ Date/Time_______________
Adapted from the American Academy of Pediatrics (AAP)
Rev 5/29/14

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Refusal To Vaccinate Refusal To Vaccinate Medical
Refusal To Vaccinate Refusal To Vaccinate Medical
Form Refusal To Vaccinate Form Refusal To Vaccinate Medical
Raising Sages Integrative Pediatrics Refusal To Vaccinate Form Raising Sages Integrative Pediatrics Refusal To Vaccinate Form Medical
Refusal To Consent To Vaccination Form (children And Adolescents) Refusal To Consent To Vaccination Form (children And Adolescents) Medical
Refusal To Receive Vaccination Refusal To Receive Vaccination Medical
Vaccine Administration Record (var) - Informed Consent For Vaccination - Influenza(flu) Vaccine Vaccine Administration Record (var) - Informed Consent For Vaccination - Influenza(flu) Vaccine Legal
Adult Screening Checklist For Contraindications To Vaccines - Jersey County Health Department Adult Screening Checklist For Contraindications To Vaccines - Jersey County Health Department Life
Vaccine Administration Record (var) Informed Consent For Vaccination Vaccine Administration Record (var) Informed Consent For Vaccination Medical
Refuse To Be Denied (d) Chord Chart Refuse To Be Denied (d) Chord Chart Life

Related Categories

Parent category: Medical
Download
Go