Heswall and Pensby Group Practice

270 Telegraph Road, Heswall, Merseyside, CH60 7SG

Telephone: 0151 342 2811

cmicb-wi.gatekeeper-N85007@nhs.net

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Childhood Immunisation Disclaimer Form

Childhood Immunisation Disclaimer Form

Name(Required)
Name(Required)
Is there sole or joint parental responsibility for this child?(Required)
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.(Required)
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.(Required)
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.(Required)
I/We have read DoH Reference guide to consent for examination or treatment (refer to the site below)(Required)
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/138296/dh_103653__1_.pdf
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.(Required)
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.(Required)
I/We understand that my/our child can be restored to tha vaccination schedule at any time by contacting the practice.(Required)
This field is for validation purposes and should be left unchanged.
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Opening Times

  • Monday
    08:00 to 18:30
  • Tuesday
    08:00 to 18:30
  • Wednesday
    08:00 to 18:30
  • Thursday
    08:00 to 18:30
  • Friday
    08:00 to 18:30
  • Saturday
    CLOSED
  • Sunday
    CLOSED
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