Our clinicians recommend that all children receive all recommended vaccinations for the purpose of individual and societal prevention of vaccine preventable illness. The AAP provides a vaccination schedule that we recommend, use, and follow. Our physicians are in agreement with experts in the field of vaccine safety and believe that the benefits of immunization far outweigh any rare risks from the vaccines.

In the past, our clinic policy has strictly required all patients receive all required vaccines. It has provided some flexibility related to so-called 'alternate schedules', so long as the overall goal is that the child eventually receives all required vaccines. However, there has been a recent and significant societal change in how some individuals view vaccines and this updated policy reflects this reality. Our commitment remains to promote all recommended vaccines and to protect the health of our community.

Although the clinic strives to provide the best care we can for your child, we must also strive to provide the best care we can for the other children playing in the waiting room or the newborn being held across from you.

All children, but especially those who are too young to receive certain vaccines or who medically cannot receive certain vaccines, need a safe environment to receive medical care. It is important to remember this fact when you choose to delay or refuse vaccine(s) for your child.

Thank you for choosing to protect your children from preventable illness and thank you for helping protect those children and adults who are vulnerable to these illnesses, including newborns, people on chemotherapy, or people with an immune system disorder. Thankfully, you are the vast majority of our families that have made the most scientifically and medically accurate and correct choice. The clinic follows all guidelines and investigates any new vaccine products before offering it to our patients so that you can trust what we are offering. We will never give a vaccine without your consent.

• None. Thank you for your trust and thank you for helping protect our loved ones

• Minimized due to good decision making

Please discuss with your provider the potential risks involved in following an alternate schedule. As long as the goal is for your child to be fully vaccinated, your alternate schedule is being followed, and the vaccination schedule is not significantly delayed, you won't be required to sit in the sick waiting room. For legal reasons you may be required to sign a form documenting your refusal.

Requirements:

• Sign legal document accepting the risk of delaying the required vaccine(s)

Risk:

• Increased depending on what vaccine is being delayed

Please discuss with your provider the potential risks involved in following a delayed schedule. As long as the goal is for your child to be fully vaccinated and the vaccine delay is not significant, you won't be required to sit in the sick waiting room. For legal reasons you may be required to sign a form documenting your refusal.

Requirements:

• Sign legal document accepting the risk of delaying the required vaccine(s)

Risk:

• Increased depending on what vaccine is being delayed

Please discuss with your provider the potential risks involved in refusing certain vaccines. You may be required to sign a legal form documenting your refusal and, based off the recommendation of your provider, you may be required to sit in the sick waiting room or your car if the vaccine being refused places other people at risk.

Requirements:

• Sign legal document accepting risk of refusing the required vaccine(s)
• Depending on the vaccine refused, may be required to wait in your car to protect infants, children, and adults around you

Risk:

• Increased depending on what vaccine is being refused

There is a lot of misinformation on the internet and social media about vaccines. It is easy to find a story of a child (allegedly) having a terrible outcome after receiving certain vaccines. What you don't hear about and what you don't see in the news and social media are the thousands of patients that we see yearly who receive all recommended vaccines and have no side effects. You don't hear about the patients we see every day who 'cried when she got the vaccine' but were back to her normal self by the time she got home. As a father, I can vouch that my kids had no side effects and were running around the house laughing and playing less than 30 minutes after receiving their required shots. Such stories aren't eye catching, though, and aren't 'news worthy' so you don't hear about it, but it reflects the vast, vast majority of people who receive vaccines. Please do not fall victim to disinformation campaigns by special interest groups or foreign adversaries attempting to convince you to place your child at risk because of an unfounded conspiracy theory or an attempt to make the average US citizen seem uneducated and foolish. No reputable authority (nor ourselves) believe that vaccines have zero risk. Vaccine reactions do occur but are very, very rare.

If you as a parent choose not to give any vaccines to your child, we ask that you find a different provider as our philosophy of protecting your child and decreasing your child's risk of a potentially lethal infection is not in line with your philosophy of refusing vaccines. We will continue to see your child until your child is medically stable enough to be let go. This may mean we will continue to see infants, patients with chronic illnesses, or families with complex medical or social issues because we feel it is in the best interest of the child to continue benefiting from receiving care in their 'medical home' with the medical team who knows their medical issues and challenges well. But when your child is medically able, the clinic may ask you to find a different provider who agrees with your vaccine philosophy.

Finally, if your child is not receiving vaccines you may be required to sit in the sick waiting room or in your car. This is not a punishment; rather, this is the clinic exercising our legal and ethical duty to protect the adults and children who enter our clinics. These families enter our building with the assumption that they are in a safe environment. These families have made the medically and scientifically sound choice to protect their children and should not be placed at increased risk due to your choices.

• Sign legal document refusing required vaccine(s)
• Wait in your car
• Begin looking for a medical clinic that is in-line with your vaccination beliefs
• Will be required to find a new provider when your child is medically stable

• Significant increase risk to your child and people around you
• Difficulty in finding a daycare, preschool, mother's day out program, pre-K program, and limited school options
• Requirement to complete vaccine refusal documentation for each school, after school program, summer program, and college your child attends

Please note, no vaccine is 100%. For example, every year we see patients who received the flu vaccine but still get the flu. This can occur with many of the illnesses below. It is important to know that the vaccine stimulates the immune system to be 'prepared' or 'ready for' the bacteria or virus if your child is exposed to it. Therefore, if your child is infected by an illness he or she received a vaccine towards, their symptoms will be significantly decreased due to your child's immune system having been previously prepared for the illness.

• Hepatitis B - Virus that can damage the liver, which can lead to cirrhosis of the liver, liver failure, and/or liver cancer.
• Diphtheria - disease caused by a bacteria that releases a toxin that damages the nose and throat. It can cause damage to the heart, kidneys, and nervous system and can be lethal even if treated.
• Tetanus - disease caused by a bacteria that releases a toxin that prevents muscles from relaxing. Also known as 'lockjaw'. It causes excruciatingly painful, seizure-like spasms that can eventually result in death from respiratory failure
• Pertussis - Highly contagious. Causes cough and congestion initially followed by uncontrolled coughing 'fits' for up to 10 weeks. It also causes apnea, cyanosis, and potentially death in infants
• Haemophilus Influenza type B - Life threatening bacterial infection, spread via coughing or sneezing, that can cause pneumonia, blood stream infections, and/or meningitis. Hib infection can result in loss of limbs, severe brain damage, or death. Children less than 5 years old are at heightened risk of infection and complications.
• Pneumococcus - bacteria that causes ear infections, pneumonia, and meningitis. Pneumococcal pneumonia can damage the lungs and heart and is lethal in 1 out of 20 infections. Pneumococcal meningitis is lethal in 1 out of 12 children and 1 out of 6 adults and those lucky enough to survive often have long-term brain damage. Pneumococcal blood stream infection is lethal in 1 out of 30 children and 1 out of 8 adults.
• Rotavirus - 'Stomach bug' virus that causes vomiting and significant watery diarrhea leading to dehydration and, potentially, death if fluids are not administered early enough
• MMR (Measles, Mumps, and Rubella) - Measles is highly contagious, causes high fever and respiratory symptoms and young children are at risk for severe complications including pneumonia and brain swelling. Mumps causes salivary gland swelling, headache, fever and can potentially cause inflammation of testicles, ovaries, pancreas, and/or the brain and spinal cord. Rubella causes cold-like symptoms but can harm a pregnant woman's developing baby which may result in miscarriage, death of the newborn shortly after birth, and heart and/or brain damage if the newborn survives.
• Varicella (Chicken pox) - Highly contagious, generally mild illness. Vaccination is required due to potential complications including pneumonia, skin bacterial infection, and brain swelling. Immunocompromised people can develop varicella infection of the internal organs. Pregnant women are at risk for pneumonia and death from varicella and her baby is at risk for skin scarring and damage to limbs, brain, and eyes.
• Hepatitis A - typically causes 'stomach bug' like symptoms but can cause damage to the liver potentially causing liver failure
• Meningococcal - Vaccine covers multiple bacteria that cause meningitis. Infection leads to death in 1 out of 10 and 1 out of 5 survivors have life-long disability
• Polio - disease caused by a virus most known for causing paralysis. Largely eliminated in the US but causes still occur internationally and, due to international travel, new cases can potentially occur in the US

I have been provided with and given the opportunity to read each Vaccine Information Statement from the Centers for Disease Control and Prevention explaining the vaccine(s) and the disease(s) it prevents for each of the vaccine(s) checked as recommended and which I have declined, as indicated above. I have had the opportunity to discuss the recommendation and my refusal with my child's doctor or nurse, who has answered all of my questions about the recommended vaccine(s). A list of reasons for vaccinating, possible health consequences of non-vaccination, and possible side effects of each vaccine is available at https://www.cdc.gov/vaccines/hcp/current-vis/index.html.

I understand the following:

• The purpose of and the need for the recommended vaccine(s).
• The risks and benefits of the recommended vaccine(s).
• That some vaccine-preventable diseases are common in other countries and that my unvaccinated child could easily get one of these diseases while traveling or from a traveler.
• If my child does not receive the vaccine(s) according to the medically accepted schedule, the consequences may include
  • Contracting the illness the vaccine is designed to prevent (the outcomes of these illnesses may include one or more of the following: certain types of cancer, pneumonia, illness requiring hospitalization, death, brain damage, paralysis, meningitis, seizures, and deafness; other severe and permanent effects from these vaccine-preventable diseases are possible as well).
  • Transmitting the disease to others (including those too young to be vaccinated or those with immune problems), possibly requiring my child to stay out of child care or school and requiring someone to miss work to stay home with my child during disease outbreaks.
• My child's doctor and the American Academy of Pediatrics strongly recommend that the vaccine(s) be given according to recommendations.

Nevertheless, I have decided at this time to decline or defer the vaccine(s) recommended for my child, as indicated above, by checking the appropriate box. I know that failure to follow the recommendations about vaccination may endanger the health or life of my child and others with whom my child might come into contact. I therefore agree to tell all health care professionals in all settings what vaccines my child has not received because he or she may need to be isolated or may require immediate medical evaluation and tests that might not be necessary if my child had been vaccinated.

I know that I may readdress this issue with my child's doctor or nurse in the future and that I may change my mind and accept vaccination for my child

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