Refusal to Vaccinate

Childs NHS Number ______________

Parent/Guardian’s Name(s):__________________________________________

I acknowledge that my child’s doctor/nurse has recommended that my child (NHS number above) receive the following vaccines in line with the national Childhood Immunisation Schedule:

DTaP/IPV/Hib			MenC
	
PCV					Hib/MenC

MMR Booster			MMR

DTaP/IPV (PSB)

Following careful consideration and after receiving all the necessary medical advice I required from my child’s doctor/nurse I have decided not to vaccinate my child with the ___________________________ vaccine.*

Parent/Guardian Signature: ___________________________ Date___________

Nurses Signature ___________________________________ Date ___________

Doctors Name: __________ __________________________ Date: ___________

Doctors Signature: _________________________________

Reason given for refusal _______________________________

*Signing this form does not prevent me from receiving this vaccine or any other vaccine should I change my mind in the future