Childhood immunisation refusal disclaimer

Child’s First Name(s): *

Child’s Last Name: *

Child’s Date of Birth: *

Your Full Name: *

Relationship to Patient: *

Phone Number: *

Email Address: *

Child’s NHS Number:

Address (including postcode):

Please indicate what vaccination(s) you do not wish your child to have by ticking the box(s) below:

Diphtheria/ Tetanus/ Pertussis / Polio/ Hib / Hepatitis B

Pneumococcal

Meningitis C

Haemophilus influenzae Type B / Meningitis C

Measles, Mumps and Rubella 1

Pre School-Booster – Diphtheria, Tetanus, Pertussis& Polio, Measles, Mumps and Rubella 2

Rotavirus

Meningitis B

I do not agree to my child receiving protection against any of the diseases stated.

Your child can be restored to the vaccination schedule at any time by contacting the practice.

Signature: *

Date:

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