Refusal to Vaccinate Form

Ensure vaccine refusals are documented and safely stored in your database.

Due to religious or philosophical reasons, some parents choose not to get their children vaccinated. This refusal to vaccinate form template can help you easily document these cases for future reference. Matrix fields have been included so doctors can record which vaccinations were recommended and declined by the parent.

Mobile-Friendly

Why use pens and clipboards when you can use a sleek mobile device instead? Doctors can pull this form up on their tablet to go over important details with the parent and make note of the amount of time spent on vaccine counseling. No cumbersome paperwork needed!

100% Customizable

Easily customize this template to meet the needs of your hospital or practice. Add your organization's logo and colors, include Description fields to lay out all the info a parent needs to agree to, and use Matrix fields to let doctors tick off recommended and declined immunizations.

Signature Ready

There's no need to print this document for signing. With the Electronic Signature field on this form template, parents can use a finger or tablet pen to sign the form on the doctor's mobile device. The signature will be saved as an image file and safely stored for future reference.

HIPAA Compliant

After you complete the refusal to vaccinate form and give a copy to the parent, you should store it for safekeeping. Use Formstack's HIPAA compliant solution to protect patient data and ensure you meet all security standards. Security features include advanced data encryption and continual security maintenance.