REFUSAL OF IMMUNIZATION FOR MEDICAL REASONS

Child’s Last Name________________________

First Name______________________

Age____ Birth Date_______ School____________________ Grade___

A. I have elected to not immunize this student against the following disease(s): (check box*)

Diphtheria...........................................................................................
Tetanus........................................................... ...................................
Pertussis.............................................................................................
Polio.................................................................... ...............................
Measles(Rubeola)..............................................................................
Mumps................................................................................................
Rubella (German Measles)................................................................
Hepatitis B................................ ..........................................................

In my opinion, this immunization would be injurious to the health and well-being of

The student........................................................................
A member of the student’s household or family..........................

B. I have elected to use the two-dose Hepatitis B vaccine series licensed by FDA for use in 11-15 year old adolescents. It could potentially be injurious to the student’s health to give a third dose that is not medically required to complete the series.

Comments __________________________________________________________

___________________________________________________________________

Signature of Physician___________________________________ Date___________

* Each disease for which a vaccine has not been administered must be checked. Parent / guardian must submit dates of immunization for all other diseases.