Patient Vaccine Refusal Policy

Amherst Pediatric Associates

Please correct the errors described below.

Amherst Pediatric Associates’ Immunization/Vaccination policy is that all patients follow, at a minimum, the New York State Immunization/Vaccination Requirements.

The 2021 New York State Immunization/Vaccination Requirements for the entrance and attendance at a New York State School include the following vaccinations:

DPT (Diphtheria, Pertussis, Tetanus)

IPV (Polio)

Varicella (Chickenpox)

MMR (Measles, Mumps, Rubella)

Hepatitis B

Prevnar (Pneumococcus)

HIB (Hemophilus Influenza Type B)

Meningococcal A, C, W, Y

New York State highly recommends the following vaccinations but does not require them for school entrance or attendance. Please note that although the following vaccinations are not required by New York State for school entrance or attendance, they can be required for International Travel, College Entrance or employment.

Hepatitis A

Meningococcal B

HPV (Human Papaloma Virus)

Annual Influenza vaccination


Amherst Pediatric Associates’ established families/patients that refuse the New York State Immunization/Vaccination requirements:

  1. Will be able to stay with the practice as an established patient.
  2. At each well visit, we will require that the “Refusal to Vaccinate” form be signed.
  3. Amherst Pediatric Associates will continue ongoing efforts to educate and encourage full immunization protection.

Potentially new patients to Amherst Pediatric Associates:

  1. ALL new patients must agree to be vaccinated to meet the New York State Immunization/Vaccination Requirements.
  2. Alternative schedules will continue to be considered as long as coverage is not delayed. (eg. Parent requesting that patient receives two vaccinations at the 2 month office well visit and the other vaccinations at 3 months of age.).
  3. Medical exemptions will be the only exception to Amherst Pediatric Associates’ Immunization/Vaccination policy.
  4. It is the opinion of Amherst Pediatric Associates that there are no legitimate religious, philosophical, or moral objections to immunizations/vaccinations.
  5. All new families/patients will be required to sign a copy of this Immunization/Vaccination Policy.
  6. Any families/patients that are not compliant with Amherst Pediatric Associates’ Immunization/Vaccination Policy may be asked to transfer their medical care to a different pediatric medical office.

I have read and understand Amherst Pediatric Associates’ Immunization/Vaccination Policy. I agree to comply with the stated provisions.

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