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Hadwen Health NHS GP Surgery in Gloucester

Child immunisation refusal

Child Immunisation Refusal

Section

GP name: *

Health visitor name:

Please select the vaccinations you are choosing to decline: *

6 in 1: Diptheria, Tetanus, Pertussis (whooping cough), Polio, Hib & Hepatitis B

Meningitis B

Rotavirus

Hib/Meningitis C

MMR (Measles, Mumps and Rubella (German Measles))

Pre-school booster: Diptheria, Tetanus, Pertussis, Polio

Pneumococcal

Confirmation *

I would like to decline the vaccinations selected above for my child at this time.

I confirm that I have parental responsibility for this child and I am authorised to confirm this decision. I have discussed this decision with anyone else that has parental responsibility for this child.

Parent/Guardian Signature *

Date

Parents and carers who choose to decline immunisations may change their decision at any time. There is no upper age limit for immunisation.

This form collects your name, date of birth, email address, and other personal and medical information. This is used to confirm your registration with the practice, allow the practice team to contact you, and update your medical records held by the practice and NHS partners. Please read our Privacy Policy to learn how we protect and manage your submitted data.

Consent *

I consent to the practice collecting and storing my data from this form.

If you are human, leave this field blank.

Glevum Way
Gloucester
GL4 4BL

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01452 529933

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