First and Last
My child's provider has advised me that my child should receive the following vaccines:
I have been provided with and given the opportunity to read each Vaccine Information Statement from the Centers for Disease Control and Prevention explaining the vaccines (s) and the disease (s) it prevents for each vaccine (s) checked as recommended and which I have declined, as indicated above. I have had the opportunity to discuss the recommendation and refusal with my child's doctor or nurse, who has answered all of my questions about the recommended vaccine(s). A list of reasons for vaccinating, possible health consequences of non-vaccination, and possible side effects of each vaccine is available at www.cc.gov/vaccines/pubs/vis/default.htm
I have been advised that it is my providers medical opinion on:
The purpose of and the need for the recommended vaccine(s)
The risks and benefits of the recommended vaccine(s)
That some vaccine-preventable diseases are common in other countries and that my unvaccinated child could get on of these disease while traveling or from a traveler.
If my child does not receive the vaccine(s) according to the medically accepted schedule, the consequences may include-
-Contracting the illness the vaccine is designed to prevent.
- Transmitting the disease to others, possibly requiring my child to stay out of child care or school and requiring someone to miss work to stay home with my child during disease outbreaks.
My child's provider and the American Academy of Pediatrics, the American Academy of Family Physicians, and the centers for disease control and Prevention all strongly recommend that the vaccines(s) be given according to recommendations.
Nevertheless, I have decided at this time to decline or defer the vaccine (s) recommended for my child, as indicated above by selecting decline for the recommended vaccines. I feel the risks of vaccinating outweigh the benefits. I have been advised that my provider's medical opinion is that vaccines are an important part of preventative medicine and the diseases for which they provide protection can be harmful. He/she has also recommended that I tell all health care professionals in all settings for which I am seeking medical care for my child, what vaccines my chid has not received, because he or she may need to be isolated or may require immediate medical evaluation and tests that might not otherwise be necessary if my child had been vaccinated.
I know that I may readdress this issue with my chid's provider at any time and that I may change my mind and accept vaccination for my child at any time in the future.
I acknowledge that I have read this document in its entirety and fully understand it, and that by signing, I am stating that this information has been shared with me, not that I agree with the opinions shared.
(first and last) Electronic Signature