PDF
Word
Vaccine Refusal Form - Five Points
A Vaccine Refusal Form is a formal document used by a patient that has decided not to take a vaccine offered by the current physician or healthcare provider they visit. Whether you are not prepared to get vaccinated at this time, you want to wait and make a choice in the future, or you believe a vaccine can be harmful to you, you can complete this form of your own accord or when your doctor offers you one to make sure your medical records reflect your decision. As long as you verify that you were explained the purpose of the vaccine and the possible consequences of not receiving it, you are free to refuse it accepting full responsibility for your choice.
A Vaccine Refusal Form template can be downloaded below. To waive your right to get vaccinated, you need to indicate your full name, date of birth, age, and gender, indicate the type of vaccine you are refusing to take, confirm your physician has informed you of the risks and benefits of vaccination, acknowledge your right to change your mind in the future and get vaccinated, and certify your refusal to get a vaccine at the moment of signing the document. If you are filling out a Vaccine Refusal Form for Adults, it must bear the signature of the individual in question; in case you are making this decision on behalf of your child, include their name and write down yours as a parent or legal guardian.
Haven't found the form you're looking for? Take a look at the related forms below:
