Join the Meeting Place for Moms!
Talk to other moms, share advice, and have fun!

(minimum 6 characters)

Refusal to Vaccinate Form

Posted by on Mar. 12, 2012 at 6:17 AM
  • 4 Replies
  • 398 Total Views

Consent Declined for Vaccines

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:

Vaccines: Recommended and/or Declined

VaccineRecommendedDeclinedDate
Hepatitis BY/NY/N__/__/__
DTaPY/NY/N__/__/__
DT or TdY/NY/N__/__/__
Haemophilus influenza type B (Hib)Y/NY/N__/__/__
Pneumococcal conjugate vaccineY/NY/N__/__/__
Polio vaccine (IPV)Y/NY/N__/__/__
Measles, mumps, rubella MMR-IIY/NY/N__/__/__
Varicella (chickenpox)Y/NY/N__/__/__
Influenza (flu)Y/NY/N__/__/__
MeningococcalY/NY/N__/__/__
Hepatitis AY/NY/N__/__/__
RotavirusY/NY/N__/__/__
Other________________________Y/NY/N__/__/__
Total _____________/__/__

I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Sheet(s) explaining the vaccine(s) and the disease(s) for which it is intended. I have had the opportunity to discuss this with my child’s health care provider, who has answered all of my questions regarding the recommended vaccine(s). I understand the following:

● The intended purpose of the recommended vaccine(s).
● The risks and benefits of the recommended vaccine(s).
● If my child does not receive the vaccine(s), the consequences may include
- Contracting the illness the vaccine should prevent. (the outcomes of these illnesses may include one or more of the following: pneumonia, illness requiring hospitalization, death, brain damage, meningitis, seizures, and deafness. Other severe and permanent effects from these vaccine -preventable diseases are possible as well)
- Transmitting the disease to others.
- The need for my child to stay out of child care or school during disease outbreaks.

●If my child does receive the vaccine(s), the consequences may include:
-Contracting the illness the vaccine should have prevented
-Transmitting the disease to others
-Suffering from any of the adverse events listed in the package insert and possibly adverse events not
yet listed and/or associated with the vaccine. (the outcomes of these adverse events may include one or more of the following: illness requiring hospitalization, death, brain damage, meningitis, seizures, and deafness. Other severe and permanent effects from these vaccines are possible as well)
-Chronic illness and/or death

● My health care provider, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention have all strongly recommended that the vaccine(s) be given based on the information they have been given by the drug companies producing the vaccines.

I have declined consent for the vaccine(s) recommended for my child, as indicated above, by checking the appropriate box under the column titled “Declined.”

I know that I may re-address this issue with my health care provider at any time, and that I may change my mind as personal beliefs are subject to evolve and change over time.

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

Parent/Guardian Signature ______________________________________

Date__/__/__

Witness___________________________________________

Date__/__/__


Choosing Not to VaccinateChoosing Not to Vaccinate-proud group owner

by on Mar. 12, 2012 at 6:17 AM
Add your quick reply below:
You must be a member to reply to this post.
Replies (1-4):
emmy526
by New Owner on Mar. 12, 2012 at 6:18 AM

feel free to copy, paste and print this to take to the pedi/drs office for them to sign.  

wolfybaby
by Bronze Member on Mar. 12, 2012 at 1:45 PM
2 moms liked this

i love it! washingtonians like me would need another line for our doctors signature. and something like "my doctor understands my rights as parent to [child], has listened to and accepted my reasons for refusal of vaccines, and will back the heck off!"

cybermom463
by Member on Mar. 13, 2012 at 8:42 AM
Thanks for posting!
Posted on CafeMom Mobile
Mschrissy007
by Member on Apr. 21, 2012 at 10:47 PM
Thank you do much

family in the vanGOD BLESS

Add your quick reply below:
You must be a member to reply to this post.
Join the Meeting Place for Moms!
Talk to other moms, share advice, and have fun!

(minimum 6 characters)