Vaccine Refusal Statement
Please complete this form to formally document your decision to decline vaccination.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Vaccine Recipient
*
Please Select
Self
Parent/Guardian
Legal Representative
Other
Name of Vaccine Being Refused
*
Reason for Refusal
*
Medical concerns
Religious beliefs
Personal beliefs
Previous adverse reaction
Other
Please provide any additional details regarding your refusal (optional)
By signing below, I confirm that I have read and understood the information provided regarding the vaccine and the potential risks associated with refusing vaccination. I acknowledge that I am making this decision voluntarily and accept full responsibility for the consequences.
*
Date of Declaration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Statement
Submit Statement
Should be Empty: