Refusal to Vaccinate Template

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As different mandates emerge around COVID-19 immunizations from the U.S. Centers for Disease Control and Prevention, businesses, education institutions, and more, many organizations are finding they need a way to track and process medical exemptions, parental refusal, and personal refusal for those opting out of vaccines. Health care providers, pediatricians, HR professionals, and others can use Formsite’s Refusal to Vaccinate Form Template to gather data securely and efficiently.

This vaccine refusal form collects all essential information, including name, date of birth, contact information, the type of vaccine being refused (examples include: polio, Tdap or DTAP [diphtheria tetanus and pertussis], Varicella, chickenpox, hepatitis A, hepatitis B, meningitis, rotavirus, the novel coronavirus, HPV, MMR [measles-mumps-rubella], and pneumococcal), the reason for refusal, and an electronic signature section that also indicates the person in question has been given information regarding vaccine safety, the role of vaccines in public health and controlling outbreaks, etc. It also includes an editable vaccine information statement that refers patients to the AAP website (American Academy of Pediatrics at and the Immunization Action Coalition at for immunization information regarding protection against vaccine-preventable diseases. T With Formsite’s import/export tools the data can be transferred to an external application for medical record updates.

All Formsite forms can be embedded into any website, or the link sent via email or made accessible via social media for convenient access. The form can be viewed with tablets or smartphones, completed, and submitted via Formsite’s secure technology. Enable optional notifications upon submission to initiate appropriate immunization requirement processes.

This template can also be easily modified using our style tools and drag and drop editor to meet your specific needs and to match your branding. Check out the sample form below.

Vaccination Refusal Form

Healthcare professionals will find it easy to use Formsite for online form creation and customization. Regardless of the type of health or medical form you need, we can help. Browse our extensive template library, and be sure to ask about our enterprise level solutions for corporations and organizations with more advanced form needs. Getting started is easy. Try Formsite today.

Refusal to Vaccinate Form

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