Free Vaccine Waiver Form Template

If you're managing a healthcare practice, patients declining vaccines can create uncertainty. This vaccine waiver form template helps you collect necessary information while protecting your practice from legal liabilities. Utilize it to ensure clarity for your patients, simplify records management, and enhance communication regarding vaccination options, all while being compliant with healthcare regulations. Experience how effortless it can be to facilitate informed consent-try the live template today.

When to use this form

Use this form when an employee, student, or patient chooses to decline a recommended or required immunization. It helps you document informed refusal, track accommodations, and meet policy or regulatory needs. Common scenarios: a school nurse collecting signed declinations for MMR or Tdap; a clinic noting a temporary medical contraindication; an employer recording staff choices during onboarding. If the situation relates only to coronavirus shots, route people to the COVID-19 Vaccine declination form. To verify history and avoid duplicate declinations, pair this with an Immunization record form.

Must Ask Vaccine Waiver Questions

Which vaccine(s) are you declining?
Listing the specific vaccine and dose keeps records precise and limits the scope of the refusal. It also triggers the right alternatives, such as testing or masking, for that vaccine only.
What is your reason for declining (medical, religious, or personal)?
This clarifies whether documentation or review is required. It speeds routing to HR, compliance, or a clinician and sets expectations for next steps.
Do you acknowledge the health risks of remaining unvaccinated and possible exclusion during outbreaks?
This documents informed refusal and shows that you understand potential exposure, transmission, and time away from work or school. If you also need permission to treat in urgent situations, collect that with an Emergency medical consent form.
Have you received any prior doses of this vaccine, and can you upload proof?
Prior doses may change risk and policy requirements. Requesting proof supports accurate records and reduces back-and-forth.
Do you agree to follow alternative safety measures and sign to confirm your statements are true?
This sets clear expectations and helps your organization manage risk. A signature and date make the waiver enforceable and audit-ready.

More Forms

Question		Response
Organization or clinic name		This is a test
Location or site (if applicable)		This is a test
Form date		2025-10-15T00:00:00.000Z
Patient full name		John Smith
Date of birth		2025-10-15T00:00:00.000Z
Phone number		555 555 5555
Email address		[email protected]
Mailing address		This is a test
Vaccine(s) you are declining today		Pneumococcal
If other vaccine(s), please specify		This is a test
Do you decline the selected vaccine(s) today?		Yes
Please provide any additional details (optional)		This is a test
Primary reason(s) for declining		Religious beliefs
I received or was offered vaccine information materials and had an opportunity to ask questions.		1
I understand that not receiving the vaccine may increase my risk of infection, serious illness, or death.		3
I understand I may be required to follow additional safety precautions as directed by my employer, school, or healthcare provider.		3
I understand I may request and receive the vaccine at a later date if I change my decision.		3
I acknowledge that my decision to decline is voluntary and made after considering available information.		2
Is the patient under 18 years of age?		No
Parent or guardian full name		John Smith
Parent or guardian phone number		555 555 5555
Relationship to patient		Mother
Type your full legal name to serve as your signature		This is a test
Signature date		2025-10-15T00:00:00.000Z
Staff or witness name (if applicable)		This is a test
Staff or witness date		2025-10-15T00:00:00.000Z

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Vaccine Waiver Form Template

Streamline Patient Vaccination Choices with Ease

When to use this form

Must Ask Vaccine Waiver Questions

More Forms

Unlock hundreds more featuresSave your Form to the DashboardView and Export ResultsUse AI to Create Forms and Analyse Results

Vaccine Waiver Form Template

Streamline Patient Vaccination Choices with Ease

When to use this form

Must Ask Vaccine Waiver Questions

More Forms

Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results