Tell us whether you accept cookies

We've put some small files called cookies on your device to make our site work. We would also like to use analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

Skip to main content

Mickleover Surgery NHS GP Surgery in Derby

Childhood immunisation disclaimer

Childhood Immunisation Disclaimer

Section

Registered GP name and address: *

Acknowledgements

Please tick each statement to confirm you understand. All must be ticked to proceed.

Immunisation protection *

I understand that the Primary Childhood Immunisation schedule will protect my child from Diphtheria, Tetanus, Pertussis (whooping cough), Polio, Haemophilus influenzae type b, Hepatitis B, Meningococcal B, Pneumococcal, Rotavirus, Meningococcal C, Measles, Mumps, and Rubella diseases.

Risk of contracting diseases *

I understand that by not having the Primary Childhood Immunisation schedule my child will be at risk of contracting vaccine preventable diseases.

Risk of spreading diseases *

I understand that by not having the Primary Childhood Immunisation schedule my child can spread these vaccine preventable diseases to other vulnerable children and adults.

Refused vaccines

Please tick any vaccines you are choosing to refuse: *

6-in-1 – Diphtheria, Tetanus, Pertussis, Polio, Hib, Hepatitis B

MenB – Meningococcal B vaccine

PCV – Pneumococcal conjugate vaccine

Rotavirus vaccine

MenC – Meningococcal C vaccine

MMR – Measles, Mumps, Rubella vaccine

Hib/MenC – Haemophilus influenzae type b / Meningococcal C

Please explain your reason(s) for refusing vaccination: *

Consent and understanding

Future consent *

I understand I can arrange for my child to be vaccinated through my GP if I change my mind at a later date.

Change anytime *

I understand there is no upper age limit for immunisation and I can change my decision at any time.

Confirmation *

I confirm I have read and fully understood the information on this refusal form and I am authorised to refuse vaccination on behalf of the above-named child.

Signature *

Date

If you are human, leave this field blank.

10 Cavendish Way
Mickleover
Derby
Derbyshire
DE3 9BJ

Get directions

01332 519160

Register with the surgery

Feedback and complaints

Wellbeing

Accessibility statement

Website policies