Childhood Immunisation Disclaimer Form

Is there sole or joint parental responsibility for this child?
I/We acknowledge that all children can be exposed to disease that can have serious, if not fatal consequences; for example, Measles, Mumps, Meningitis and Polio. The only way to protect children is by immunisation; this will also help to protect other people with whom the child may come into contact, such as those with weakened immune systems, newborn babies or the elderly.
I/We also acknowledge that immunisation is the safest and best defence against epidemics that can kill or disable both adults and children. I/We understand that vaccines work by making the body produce antibodies which are used. to fight diseases without infecting the person with the disease.
I/We understand that the Department of Health (DoH) states that immunisation is an 'important decision' and immunisations should not be administered if two adults with parental responsibility cannot reach an agreement.
I/We have read DoH Reference guide to consent for examination or treatment (refer to the site below)
I/We would like to advise the practice that I/we do not wish for my/our child to participate in the NHS childhood immumisation schedule.
I/We assume full responsibility for my/our decision and confirm that I/we have read and understand the above statement about the associated risks and benefits and the importance of childhood immunisations in reducing the risk of my/our child contracting serious, potentially fatal diseases.
I/We understand that my/our child can be restored to tha vaccination schedule at any time by contacting the practice.
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