Childhood Immunisation Disclaimer Form

 

 

Childhood Immunisation Disclaimer Form (1)

This field is for validation purposes and should be left unchanged.
Name  Required
Name  Required
Is there sole or joint parental responsibility for this child?  Required
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.  Required
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.  Required
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.  Required
I/We have read DoH Reference guide to consent for examination or treatment (refer to the site below)  Required
https://tinyurl.com/ucfx79j5
I/We would like to advise the practice that I/we do not wish for my/our child to participate in the NHS childhood immumisation schedule.  Required
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.  Required
I/We understand that my/our child can be restored to tha vaccination schedule at any time by contacting the practice.  Required

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