Originally Posted by mamabain
i wish i hadn't gone. yesterday i took my 2 yo and 5 yo to wbv, just to get to know the ped. youngest hadn't been and oldest hasn't since she was maybe 2. well, i refused the vaxes. doctor came in with a waiver for me to sign, from the AAP. i told her i might be able to sign it if i could cross some things out.
here is the form: http://www.cispimmunize.org/pro/pdf/..._2pageform.pdf
i crossed out this statement and signed it: I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others that my child might come in contact with.
she wasn't happy with my crossing out that statement and came back in and said she wasn't comfortable and that she wouldn't see my kids.
i only wanted to have a relationship with a doctor in case we need one. i'd like to have someone who knows my girls be able to treat them. i guess we are searching again...
just thought i'd share my experience.
Ugh, I hate that form, which is why I made a revised version of it, that way you can present the ped with a form with nothing crossed out....
Modified Refusal to Vax Form, and notice the words "refusal to" were omitted
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:
Hepatitis B vaccine
Diphtheria, Tetanus, acellular Pertussis (DTaP) vaccine
Diphtheria Tetanus (DT or dT) vaccine
Haemophilus influenzae type B (Hib) vaccine
Pneumococcal conjugate vaccine
Polio vaccine (IPV)
Measles, mumps, rubella (MMR) vaccine
Varicella (chickenpox) vaccine
Influenza (flu) vaccine
Hepatitis A vaccine
I have read the Centers for Disease Control and Prevention’s (CDC) Vaccine Information Sheet(s)
explaining the vaccine(s) and the disease(s) it prevents. 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 and the need for 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__________________
This form basically states one is aware of the risks and benefits of vaccines, changes the damaging information, and adds more to the risk side which is blatantly absent from the original document. There is no medical reason stated for declining vaccines, as this may be used against someone attempting to file for a religious exemption. Also keep in mind that one can modify these forms any way they choose to reflect their unique situation.
This should satisfy a drs need to have something on file that shows the parent has declined the vaccines (and again, notice that this form does not state a reason for declining) to keep in the files.