Vaccine Refusal form


What is a Vaccine Refusal Form?

A Vaccine Refusal form is a document used to indicate an individual’s decision to decline a vaccination. The form must be signed by the patient, parent or legal guardian and serves as a formal record of their decision.

What are the components of a Vaccine Refusal form?

Some common components of a Vaccine Refusal form are:

  1. Personal Information: Individual’s full name, date of birth, address, and contact details
  2. Vaccine Information: Details about the specific vaccine(s) being declined, such as the name of the vaccine, the disease it prevents, and the date it was recommended or required.
  3. Statement of Refusal: This is a statement where the individual explicitly expresses their refusal or declination of the vaccination.
  4. Reasons for Refusal: This section allows the individual to explain the reasons for their refusal.
  5. Signature: The form usually includes a space for the individual or their legal representative to sign and date the document.
  6. Witness or Healthcare Provider Signature: In some cases, a witness or a healthcare provider may be required to verify the individual’s signature or provide additional information or documentation.

What is the purpose of a Vaccine Refusal form?

Vaccine Refusal forms serve as a formal record of an individual’s decision to decline a vaccination and provides a means for healthcare authorities to track vaccination compliance and accordingly form public health strategies. Additionally, Vaccine Refusal forms provide legal protection for healthcare institutions at it demonstrates that they fulfilled their duty of informing individuals about the vaccination.

Why you should digitize this Vaccine Refusal form?

Easy Compliance and Data Security: The form is designed to be HIPAA-compliant, with rigorous security mechanisms in place to ensure that you securely contact your patients with end-to-end encryption.

Integration with EHR: Emitrr automatically syncs the form responses to your health record system, reducing manual data entry.

Improve Operational Efficiency: Emitrr’s patient engagement solution is simple, user-friendly, and lets your clinical support staff save 3-4 Hrs daily by eliminating the need for manual paperwork, allowing for more efficient workflows.

Cost Savings: By transitioning to digital forms, your organization can significantly cut costs associated with paper, printing, and storage. Additionally, staff employees may better manage their time by focusing on patient care and other value-added duties rather than paperwork.

Enhanced Patient experience: Experience a significant 70% improvement in patient experience by enabling patients to remotely fill the form using any device prior to their appointments, creating a more user-friendly and convenient process.

Enhanced Accuracy: With our digital form, you can be certain of error-free submissions and gain access to precise and reliable patient data.

What are some of the best practices to consider while using the Vaccine Refusal form?

Some of the things to keep in mind while creating and dealing with a Vaccine Refusal form are:

  • Ensure HIPAA-compliance
  • Ensure that the forms are concise, clear and user-friendly
  • Track form completion live
  • Ensure that you gather all required information from the patient such as statement of refusal, reasons for refusal, etc.
  • Obtain the patient’s explicit consent and ensure they are aware of the vaccine, its benefits, potential risks, and the importance of vaccination
  • Continuously review and update the forms based on patient’s feedback and changes in clinical guidelines
  • Integrate the digital form with your healthcare facility’s EHR system to facilitate easy transfer of the form content to the patient’s health record 
  • Ensure that the form is compatible with all types of devices