Childhood immunisation disclaimer

We understand you may have some concerns or question regarding your Childs immunisations. If you wish to read more about vaccination you can visit this website: Why vaccination is important and the safest way to protect yourself - NHS. If after reading the above you have decided for your child not to have the vaccination(s) use this online form to opt out. Your child can be restored to the vaccination schedule at any time by contacting the surgery.

 

  • Childhood immunisation disclaimer

    Acknowledgement of Risk

    Before proceeding, please confirm that you understand the following:

    I/We understand that by not following the Primary Childhood Immunisation schedule, my child may be at risk of contracting vaccine-preventable diseases.
    I/We understand that the Primary Childhood Immunisation schedule protects against Diphtheria, Tetanus, Pertussis (whooping cough), Polio, Haemophilus influenzae type b, Hepatitis B, Meningococcal B, Pneumococcal disease, Rotavirus, Meningococcal C, Measles, Mumps, Rubella and Varicella.
    I/We have had the opportunity to access information about childhood vaccinations and to discuss any concerns with a healthcare professional if required.
    I/We understand that my child may transmit vaccine-preventable diseases to other vulnerable children and adults if unvaccinated.
    Vaccines Being Refused. Please select all vaccines you wish to refuse:
    I/We understand that I/we can change my decision and arrange vaccinations for my/our child at any point in the future by contacting the practice.
    I /We understand that the practice may retain a record of this decision within my/our child's medical record.
    Date of Birth:
    For example, 15 3 1984
    Date of Birth:
    For example, 15 3 1984
    Date
    For example, 15 3 1984
The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.
This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.
Page last reviewed: 09 June 2026
Page created: 08 October 2026