Childhood Immunisation Refusal Form

If you wish to refuse any childhood immunisations for your child, please complete this form.

(* = required field)

Parent/Legal Guardian details

Relationship to Child *

Child's details

Acknowledgement of Risk

Before proceeding, please confirm that you understand the following:
I 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 understand that by not following the Primary Childhood Immunisation schedule, my child may be at risk of contracting vaccine-preventable diseases. *
I understand that by not following the Primary Childhood Immunisation schedule, my child may be at risk of contracting vaccine-preventable diseases. *
I 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: *

Reason for Refusal

NHS Immunisation Guidance

Before submitting this form, please review the official NHS guidance on childhood vaccinations:

NHS Vaccinations Guide:
nhs.uk/vaccinations

Confirmation & Authority

I have read the NHS immunisation guidance above. *
I may arrange vaccination through my GP in the future if I change my mind. *
I am authorised to refuse vaccination on behalf of the above-named child, and the information provided in this form is accurate and complete. *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *

 

Training Days

On the following dates the surgery will be closed from 1pm for training and will re-open the following day at normal hours:

Thursday 2nd July 2026
Thursday 10 September 2026
Thursday 8th October 2026
Thursday 5th November 2026
Thursday 14th January 2026
Thursday 4th February 2027
Thursday 4th March 2027