Childhood Immunisation Disclaimer

Sign the form below if you do not want your child immunised against diseases.

Please read each statement carefully.

You should read the Department of Health (DoH) Reference guide to consent for examination or treatment before making a decision.

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

Childhood Immunisation Disclaimer Form
I / We acknowledge that all children can be exposed to disease that can have serious, if not fatal consequences; for example, Measles, Mumps, Meningitis and Polio. The only way to protect children is by immunisation; this will also help to protect other people with whom the child may come into contact, such as those with weakened immune systems, newborn babies or the elderly. *
I / We also acknowledge that immunisation is the safest and best defence against epidemics that can kill or disable both adults and children. I / We understand that vaccines work by making the body produce antibodies which are used to fight diseases without infecting the person with the disease. *
I / We understand that the Department of Health (DoH) states that immunisation is an “important decision” and immunisations should not be administered if two adults with parental responsibility cannot reach an agreement. If one adult consents and the other disagrees, the immunisation should not be carried out unless both adults with parental responsibility can agree to the immunisation: *
I / We have read DoH Reference guide to consent for examination or treatment (see link in the main text): *
I / we would like to advise the practice that I / we do not wish for my / our child to participate in the NHS childhood immunisation schedule. *
I / We assume full responsibility for my / our decision and confirm that I / we have read and understand the above statement about the associated risks and benefits and the importance of childhood immunisations in reducing the risk of my / our child contracting serious, potentially fatal diseases. Please do not send me / us any further invitations for childhood immunisations. *
I / We understand that my / our child can be restored to the vaccination schedule at any time by contacting the practice. *
Please use this date format: DD/MM/YYYY.
Is there sole or joint parental responsibility for this child? *

Adult with Parental Responsibility 1

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Adult with Parental Responsibility 2

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.
We confirm we have joint parental responsibility and are in agreement about this decision: *