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Vaccine Refusal Form Template

Simplify Documentation for Patients Who Refuse Vaccination

If you encounter patients who refuse the COVID-19 vaccine, a well-structured form can streamline your documentation process. This vaccine refusal form template is designed to help healthcare professionals collect important information from patients, ensuring that you document refusals accurately while maintaining compliance. With this template, you can easily record patient medical history, track vaccination hesitancy trends, and streamline communication with your staff, all ensuring smoother patient interactions. Start using our user-friendly template to manage refusals effectively.

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Patient full name
Date of birth
Home address
Phone number
Email address
Patient ID or medical record number (optional)
Vaccines you are declining today (select all that apply)
Please Specify:
Other vaccine or vaccines declined (specify)
Primary reason for declining
Please Specify:
Additional details about your decision (optional)
Is this decision temporary or ongoing
Temporary delay
Permanent refusal
Unsure
I was offered the recommended vaccine or vaccines today.
Yes
No
I received and had the opportunity to read the Vaccine Information Statement or equivalent information for each vaccine offered.
Yes
No
My questions about the vaccine or vaccines were addressed.
Yes
No
I understand that declining may increase the risk of illness for me or my child and others.
Yes
No
I understand I may change this decision at any time by contacting my healthcare provider.
Yes
No
Emergency contact full name
Emergency contact phone
Emergency contact relationship
Parent or guardian
Spouse or partner
Sibling
Relative
Friend
Other
Please Specify:
Counseling provided by
Date counseling provided
Witness name (if used)
Notes for record (optional)
VIS edition date documented
Yes
No
Signer full legal name (type to sign)
Date signed
Signer relationship to patient
Self
Parent
Legal guardian
Medical power of attorney
Other
Please Specify:
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Home address","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a vaccine refusal form for an article on Vaccine Refusal Form Template and FormCreatorAI

When to use this form

Use this form when a patient, parent, or employee declines a recommended vaccine and you need a clear record of informed refusal. It is useful at clinics, pharmacies, schools, camps, and long-term care. For minors, collect the signature of the legal decision-maker and note the reason, so staff can update care plans and outbreak protocols. Attach it to the Immunization record form to keep history in one place. If a child is often accompanied by someone else, pair it with a Caregiver consent form to streamline future visits. A well-documented refusal of vaccination form reduces disputes, supports education, and guides follow-up if the person later chooses to vaccinate.

Must Ask Vaccine Refusal Questions

  1. Which vaccine(s) are you declining today?

    This pinpoints the scope of refusal, so you can adjust the care plan and document exactly what was declined. It also supports accurate coding, inventory tracking, and scheduling if the person later decides to receive it.

  2. What are your main reasons for declining?

    Understanding the reason helps you tailor education and address concerns respectfully. It guides follow-up outreach and reduces back-and-forth.

  3. Do you acknowledge that you reviewed risks, benefits, and alternatives and still choose not to vaccinate?

    Confirming informed decision-making shows you discussed benefits, risks, and disease complications, which strengthens documentation. It also reduces liability and improves public health conversations.

  4. Is this refusal for yourself or for a minor, and if for a minor, what is your relationship and legal authority?

    Signer identity and authority determine who can lawfully refuse and who must sign. If a child may receive care without a parent present, use the Medical consent form for minor form to keep authorizations clear.

  5. If you cannot be reached during an exposure or urgent situation, who may make medical decisions on your behalf?

    During outbreaks or reactions, you may need quick consent from a designated contact. Document a backup decision-maker, and consider the Emergency permission form for broader treatment decisions.

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