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242 Posts
Discussion Starter · #1 ·
I just brought DS in for his 9mo check up Monday and I was given a "Refusal to Vaccinate" form to sign. After searching for a Dr forever I've finally found a Physicians Assistant who is great with my kids and respectful of my wishes to delay vaccinations. Anyway she presented this form to me asking me to sign. I asked to take it home to read it and discuss it with DH, she had no problem with that. I was just wondering if anyone else who has chosen to delay or not to vaccinate has been presented with such a form and what to do. It seems harmless enough, but I am very leary!!

It basically lists all the vaccinations that have been recommended then states that my health care provider has answered all my questions and that I understand the purpose of vax and risk and benefits of vax and the consequences of not vaxing. And that vax are STRONGLY reccomended. And I quote:"NEVEVERTHELESS I have decided to decline.......I know that failure to follow the recommendations about vax may endanger the health or life of my child and others that my child might come in contact with."
That is really irritating and I feel that statement is such a lie. Anyway what do I do with this form? What are my rights?? I feel it is just to cover my PAs behind, but don't want to sign anything that could be used against me.


6,466 Posts
I would never, ever, sign such a punitive form. If they say that you must sign a form I would use the link up above provided by the pp or write your own. That form basically states that you are knowingly putting your children in danger, and you are okay with it. There are many issues sorrounding the vaccination industry and practice, so it's only natural that parents will have some aversions, and some will choose not to vax at all. I agree that the form could be used against you, so I would not go near it.

2,203 Posts
The refusal form has been modified since I modified my own version, here is my modfied version to "match" their new version....

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:

Recommended Declined
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
Meningococcal vaccine
Hepatitis A vaccine
Rotavirus vaccine
Other ____________________________________

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__________________

3,949 Posts
Thanks for the alternates suschi and trishy....I have worried about those kind of forms too, Rie. When I had a homebirth I signed a form that pretty much said: CA requires doctors at homebirths, no doctors will attend a homebirth, so don't sue the midwives for not having a doctor here.

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