Your doctor may hand you a form to sign. I would not use his form but instead have this one ready and filled out.<br><br>
They just want something in their files.<br><br><br>
You can copy and past to a sheet of paper. The format or text can be changed to fit your child.<br><br><br><div style="margin:20px;margin-top:5px;">
<div class="smallfont" style="margin-bottom:2px;">Quote:</div>
<table border="0" cellpadding="6" cellspacing="0" width="99%"><tr><td class="alt2" style="border:1px inset;">Consent Declined for Vaccines<br><br><br>
Child’s Name ____________________________________Child’s ID___________________<br><br>
Parent’s Name______________________________________________ ____<br><br>
My child’s health care provider, ____________________________, has advised me that my child (named above) should receive the following vaccines:<br><br>
Recommended /Declined<br>
☐ Hepatitis B vaccine ☐<br>
☐ Diphtheria, Tetanus, acellular Pertussis (DTaP) vaccine☐<br>
☐ Diphtheria Tetanus (DT or dT) vaccine☐<br>
☐ Haemophilus influenzae type B (Hib) vaccine ☐<br>
☐ Pneumococcal conjugate vaccine ☐<br>
☐ Polio vaccine (IPV) ☐<br>
☐ Measles, mumps, rubella (MMR) vaccine ☐<br>
☐ Varicella (chickenpox) vaccine ☐<br>
☐ Influenza (flu) vaccine ☐<br>
☐ Meningococcal vaccine ☐<br>
☐ Hepatitis A vaccine ☐<br>
☐ Other ____________________________________☐<br><br>
I have read the Centers for Disease Control and Prevention’s 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<br>
recommended vaccine(s).<br><br>
I understand the following:<br><br>
The intended purpose of and the need for the recommended vaccine(s).<br>
The risks and benefits of the recommended vaccine(s).<br>
If my child does not receive the vaccine(s), the consequences may include<br>
- Contracting the illness the vaccine should prevent.<br>
- Transmitting the disease to others.<br>
- The need for my child to stay out of child care or school during disease<br>
outbreaks.<br><br>
If my child does receive the vaccine(s), the consequences may include:<br>
-contracting the illness the vaccine should have prevented<br>
-transmitting the disease to others<br>
-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.<br>
-chronic illness and/or death<br><br>
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<br>
producing the vaccines.<br><br>
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”.<br><br>
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.<br><br>
I acknowledge that I have read this document in its entirety and fully understand it.<br><br><br>
Parent/Guardian Signature<br><br>
______________________________________Date________ __________<br><br><br><br>
Witness___________________________________________ __________<br><br>
Date__________________</td>
</tr></table></div>
