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Documenting a Refusal to Consent to Vaccination forms

The Refusal to Consent to Vaccination forms are a tool for office practices to use for documentation in the patient’s medical record. These forms were adapted from the American Academy of Pediatrics (AAP) forms.

The forms to document refusal to consent to vaccination for children, adolescents, and adults can be found on the Alliance for Immunization in Michigan (AIM) coalition website under the "Document" section.

Contact your local health department for more information. Remember to document vaccine refusal in the Michigan Care Improvement Registry (MCIR).

This is not a waiver form. Click here for information about immunization waivers.