Child immunisation refusal

If you choose not to proceed with a recommended immunisation, you can use this service 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 note that you can change your mind at any time.

You can use this service if you:

• are registered at the surgery

Before you start

We’ll ask you for:

• your first and last name, date of birth, sex, postcode, email and phone number
• if applicable, the details of the person you are completing the form on behalf of

Start now

You can also phone us on 01452 529933.