Vaccine Refusal Form

Vaccine Refusal Form
Full Name
First NameLast Name
Gender
Date of Birth
MonthDayYear
Date
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
I was informed about the Coronavirus Disease (COVID-19) and its possible consequences that might occur when the vaccine is declined.
I understand that COVID-19 has caused a pandemic that involves high risk to the health and life of individuals.
I was informed about the both benefits and risks of the COVID-19 vaccine.
I was recommended to get vaccinated to protect myself and people around me.
I may decide to get vaccinated at a later time under the vaccination availability conditions at that time.
Date
MonthDayYear
Date
Individual Signature
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