I have been offered a copy of the Vaccine Information Statement (VIS), which explains the vaccines and the diseases they help prevent. I talked with my child’s provider and got answers to all my questions about the recommended vaccines.
I understand:
- The illnesses each vaccine is designed to prevent.
- The benefits and possible side effects of the recommended vaccines.
- If my child does not get these vaccines on our recommended schedule, they could:
- Catch preventable diseases that could develop complications, leading to hospitalization, long-term impact, or even death.
- Spread these diseases to other people.
- Be required to stay home from childcare and/or school during outbreaks for the duration of the contagious period, which in some illnesses can last weeks.
Allegro Pediatrics strongly recommends following the standard vaccination schedule. Despite knowing this, I am choosing to delay or decline the above vaccines for my child. I understand that by not following these recommendations, I may put my child’s health and the health of others at risk. I know that my child’s provider will remain available to answer questions and that I can change my mind and choose to have my child vaccinated in the future.
With my signature, I acknowledge that I have read this document, that I have read or declined to read the VIS and other supporting documentation provided, fully understand the risks, and accept the responsibility and consequences for my decision.