A Refusal of Recommended Immunizations Form is a legal document used when a parent or guardian declines one or more vaccinations for their child. It confirms that the provider has explained the benefits and risks of immunization, and that the parent has chosen to refuse despite medical recommendations. This form protects the practice legally and documents informed refusal.
Documents Informed Refusal
Ensures that parents understand the potential health risks of declining recommended vaccines.
Reduces Legal Risk
Protects the provider and practice by formally recording the refusal and the education provided.
Fulfills Public Health Requirements
Meets state or institutional documentation requirements for vaccine exemptions or school entry waivers.
Supports Transparent Communication
Encourages open, respectful dialogue about vaccine hesitancy without interrupting care.
Tracks Refusals Over Time
Helps practices monitor patterns of vaccine refusal and follow up at future visits.
Pediatric and Family Medicine Clinics
Used when parents decline childhood immunizations such as MMR, DTaP, polio, or varicella.
School and Sports Physicals
Document refusals when immunizations are required for school enrollment or extracurricular participation.
Hospital or Birth Center Discharges
Used when newborn vaccines (e.g., Hepatitis B) are declined at birth.
Public Health Clinics
Required when patients decline vaccines offered at outreach or mobile vaccination events.
Specialty Care Referrals
May accompany patients referred to other specialists who require proof of immunization history.
Child and Guardian Information
Includes name, date of birth, and contact details for clear identification.
Vaccines Being Declined
Lists the specific immunizations refused (e.g., all vaccines, or specific ones like MMR or flu).
Risk Acknowledgment Statement
Clearly outlines the potential health risks of not vaccinating, including exposure to serious illness, complications, and outbreaks.
Provider’s Explanation
Confirms that the clinician provided education on vaccine benefits, risks, and consequences of refusal.
Parent/Guardian Signature
Acknowledges understanding of the risks and confirms the decision to refuse.
Provider Signature and Date
Documents the clinician’s role in counseling and confirms the date of refusal.
Present Respectfully
Offer the form in a non-confrontational manner during the vaccine discussion.
Provide Vaccine Education Materials
Include Vaccine Information Statements (VIS) or CDC educational handouts during the visit.
Revisit at Future Appointments
Re-discuss immunizations at each visit to offer another opportunity for reconsideration.
Keep a Signed Copy in the Chart
File the signed refusal form in the child’s medical record to ensure compliance and legal protection.
Update Annually or as Needed
Repeat the form if the parent refuses additional vaccines at a later date.
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