Vaccine Exemption Forms

Vaccine Exemption Forms


Vaccine Refusal / Exemption Forms

Below, you will find a right to refuse vaccinations form that we typically use.  We have this one displayed for you to copy and paste.  We also have the right to refuse Hep B in hospital for newborn as well as a right to refuse a TB test (refusal forms below).  Please realize that should you sign one of the vaccination refusal forms from your doctor’s office or the hospital, you may be acknowledging that you are putting your child’s life in danger.  Read the forms very carefully and do not acknowledge anything that states vaccines saves lives, are necessary for health, etc. When these in-office or in-hospital refusal forms are signed by parents they could be used against parents for endangerment of a child by Child Protective Services.

Vaccine Refusal Form

We, _________________________, hereby state that we have chosen not to vaccinate our child,_________________ because we are philosophically opposed to the concept of vaccines.

We maintain this is a responsible and ethically justifiable position for the following reasons:

-vaccination is a medical intervention performed on a healthy child that has the ability to result in injury or death of that child;

-the fact that there can be no guarantee that the deliberate introduction of killed or live microorganisms into the body of a healthy child will not compromise the health or cause the death of that child, either immediately or in the future;

-no predictors have been identified by medical science that can give advance warning that injury or death may occur in any individual child;

-there are no guarantees that the vaccine will indeed protect the child from contracting a disease;

-there is an absence of adequate scientific knowledge regarding the way vaccines singly, or in combination, act in the human body at the cellular and molecular level.

Therefore, we believe that vaccination is a medical procedure that could reasonably be termed as experimental each time it is performed on a healthy child.  

Our state law makes provisions for non-vaccination of children whose parents object to vaccines for religious or philosophical reasons.  We accept full responsibility for the health of our child, and because of philosophical conviction, do not wish our child vaccinated.  In the event of any infectious condition, our child would of course remain at home.  We further understand that during the course of an outbreak of any so called "vaccine preventable disease" would occur at your facility, our child is subject to exclusion from your facility for the duration of the outbreak.

________________________________________ _______________________
________________________________________ _______________________

Hep B In-Hospital Vaccination Refusal

DATE: __________________________

To All Doctors and hospital personnel:

This is to inform you that we are refusing the hepatitis B shot for our new born baby.

This letter is intended to supersede any consent, implied or otherwise, to papers signed at the time of, or before, hospital admission for the birth of our child.

The legal position on this is clear: however convinced a doctor-or nurse-may be that certain a treatment is in a patient’s best interest, no medical treatment may be given without the patient’s consent.

We want to be very clearly understood: we do NOT give consent for the vaccine to be given.


_________________________________________, mother

_________________________________________, father

TB Testing

To Whom It May Concern:

I hereby declare that, I, ____________________________________, withhold my consent on Tuberculosis screening on the grounds that such testing is in violation of my United States of America Constitutional 1st Amendment Right to religious freedom. It would be a violation of my religious beliefs to knowingly contaminate the body with inorganic and/or organic substances, such as the mycoplasma antigens, that can cause injury, illness, or other harm to my well-being.

  • The Tuberculin Purified Protein Derivative (Mantoux skin test). TubersolT determines that a person has been previously exposed to or had a previous infection by M. tuberculosis or a variety of non-tuberculosis bacteria. A positive reaction may also represent an allergic reaction to the components of the test. It cannot tell whether a person has active tuberculosis disease.
  • TubersolT contains Tween 80T as preservatives. A very recent study (December, 2005) discovered that Tween 80T , also known as polysorbate 80, can cause anaphylaxis, a potentially fatal reaction characterized by a sharp drop in blood pressure, hives, and breathing difficulties in persons previously exposed. Researchers concluded that the anaphylactic reaction was not a typical allergic response caused by histamines and IgE antibodies, but it was caused by a serious disruption that had occurred within the immune system. REF: Coors, Esther A, et. al. "Polysorbate 80 in medical products and nonimmunologic anaphylactoid reactions." Annals of Allergy, Asthma and Immunology. 95 (2005): 593-599.
  • I further assert the following:

  • There is no tuberculosis epidemic in ___________________________[city] to warrant the mandate of such testing.
  • There is no tuberculosis crisis at the ___________________________ to warrant the mandate of such testing.
  • Symptoms commensurate with tuberculosis are known to be:
    1. Coughing up blood/ Chest infection
    2. Severe weight loss
    3. Night sweats
    4. Constant exhaustion
    5. Loss of appetite

    I, _______________________ have not exhibited any of these of symptoms. There is no reason to suspect that I may be infected with Tuberculosis.

  • The CDC reports the following persons represent these high-risk categories for contracting TB:
  • Those coming into close contact with persons known or suspected to have TB
  • Foreign-born persons from areas where TB is common: Asia, Africa, or Latin America
  • Elderly persons (over 65 yrs.)
  • Health care worker who serves high risk patients-AIDS, TB, indigent
  • Healthcare worker in close contact with medically underserved, low income populations
  • I am not an Intravenous Drug Abusers
  • I, _______________________ do not fall into any of these categories. The chance that I may be infected with Tuberculosis is minute and thus, provides no basis to suspect I may be infected with Tuberculosis.

    Overall, I am a healthy adult who poses no serious, infectious health threat to others. My overall good health has been confirmed during visits to my primary physician and other healthcare givers.

    I have included these assertions to show that by not being tested for Tuberculosis, I pose no threat to the health and well-being of others here at _______________________________________.



    Notary Public:

    __________________________                           ______________________
    Signature                                                          Date

    __________________________                           ______________________
    City, State                                                         My Commission expires

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