All Vaccination Declination Form - Medical - Network Interpreting Service

Name(Required)

First & Last

Position

Date of Birth(Required)

Vaccines Declined(Required)

Please check each vaccine for which you are requesting a declination:

Influenza (Flu) Vaccine

Varicella (Chickenpox) Vaccine

Hepatitis B Vaccine

Measles, Mumps, Rubella (MMR) Vaccine

Tetanus, Diphtheria, Pertussis (Tdap) Vaccine

Covid-19 Vaccine

To be completed by a licensed healthcare provider

Medical Condition/Contraindication (do not include diagnosis if not necessary):

Expected duration (if temporary):

Provider Name(Required)

First & Last

Provider Signature(Required)

Date(Required)

Provider Address(Required)

Street Address City State ZIP Code

Provider Phone Number(Required)

To be completed by interpreter

Interpreter Signature(Required)

Date(Required)

All Vaccination Declination Form – Medical