Vaccine Policy

The Children’s Clinic of Conway and Greenbrier, along with the Arkansas Department of Health, the American Academy of Pediatrics, the Centers for Disease Control, the World Health Organization, and numerous other medical groups, organizations, hospitals, and clinics world wide acknowledge that modern vaccines provide tremendous benefit in the prevention and control of certain serious diseases. As such this clinic, along with many other clinics, has a vaccine policy that patients and families must abide by in order for this clinic to provide medical services to its patients. Waiver forms and exemptions from the state cover childcare facilities, public school, private school, as well as colleges and universities.These forms do not pertain to a medical facility such as this medical clinic.

►I understand that the clinic has a vaccine policy. This vaccine policy requires that the patients under the clinic’s care are following the recommended AAP schedule for vaccinations or one of our providers have approved an alternate schedule.

►I understand that if I choose to refuse all vaccines that I will be required to find a new medical office that is aligned with my vaccination preferences/beliefs. This vaccine policy is required by the clinic in order to keep our patient population and the medical staff safe from vaccine preventable illnesses.

►I understand that The Children’s Clinic providers may elect to continue seeing my child despite my vaccine refusal if the providers feel it is in the best interest of my child to have a stable medical home. I understand that this status will be reviewed periodically and, once safe to do so, I may no longer be able to bring my child to The Children’s Clinic due to my refusal to vaccinate my child.

►I understand that my child and I may be required to wait in my car (vs the waiting room) to prevent other children from getting sick from a vaccine preventable illness (for example, pertussis)

►I understand that I will receive a ‘vaccine packet’ providing information about vaccine preventable illness and that there is some required legal paperwork that needs to be completed annually while my child remains under the care of The Children’s Clinic.

I, Caregiver's Name* , acknowledge that I have read the above summary of the clinic’s vaccine policy.

Below is my vaccination intention for the children listed on the first page (Patient 1, Patient 2, and Patient 3) [of the new patient paperwork]. I understand my current intention is not legally binding and the clinic agrees it will not use this information to coerce or require that my child receive any vaccine at any time. I understand that, despite my intentions listed below, it is my (or another legal guardian or a listed proxy) decision whether to consent to vaccine administration at the time of the visit and it is my legal right as a legal guardian to refuse medical treatment, including vaccines, I do not agree with.

Patient 1*

Follow AAP schedule for full vaccinationDelay certain vaccines or follow alternate scheduleRefuse all vaccines

Patient 2

Follow AAP schedule for full vaccinationDelay certain vaccines or follow alternate scheduleRefuse all vaccines

Patient 3

Follow AAP schedule for full vaccinationDelay certain vaccines or follow alternate scheduleRefuse all vaccines

Please list the Name and DOB of Patient 1*

Please list the Name and DOB of Patient 2, if applicable

Please list the Name and DOB of Patient 3, if applicable

*The signature below covers the above authorizations and consents for all patients listed on the first page.

Signature*

Date