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Vaccine Refusal Form


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 Òvaccine preventable diseaseÓ would occur at your facility, our child is subject to exclusion from your facility for the duration of the outbreak.

______________________________Name   ____________ Date

______________________________Name   ____________ Date

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Monday:

BY APPT ONLY

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Tuesday:

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Wednesday:

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Thursday:

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Friday:

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Saturday:

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Testimonials

Reviews By Our Satisfied Patients

  • "I have had at least 4 Doctors of Chiropractic work on me. I was skeptical to have another work on me but I gave Dr. D a chance. Thank God I did! I almost forgot how it felt to be out of pain. I am on my feet all day and I can now do things I hadn't been able to do before. I realize that I have a more positive outlook as to what tomorrow will bring due to the fact that I can wake up without pain."
    Mike A.
  • "I had completely given up on chiropractic. I was going consistently for over 9 months and was actually getting worse. I was using a walker and my husband had to take me everywhere. A friend recommended that I give Dr. D a chance. He did something more than the typical chiropractor. A non force technique I think it was called. Well in a nutshell, I did go, and in a relatively short period of time I was out of my walker and able to cook and garden in my yard. I can do things I thought I would never be able to do again. My husband thanks Dr. D and I thank Dr. D for his kind caring work."
    Rose S.
  • "Dr. D took away my headache and wrist pain. I didn't even tell him that I had those problems. I came in because I hurt my low back. I can't tell you how glad I was to find the doc."
    Tonya B.