Child Immunisation Refusal Form

If you choose not to proceed with a recommended immunisation, you can use this form to officially decline the vaccination. By completing the form, you confirm that you understand the benefits of the immunisation and the potential risks of not receiving it. This form will be kept on the patient’s medical record.  Please be reminded that you may change your mind at any time.

Last Updated: 15/10/2024

Your Child's Personal Details










Declining a child immunisation

Please indicate which vaccine(s) are not required by ticking (✓) the box *





Parents/Carer who refuse immunisation(s) are reminded that they may change their minds at any time. There is no upper age limit for immunisation.


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