Vaccine Consent

Attached you will find a copy of the proposed immunization schedule for vaccines given in our offices. This schedule follows the guidelines of the American Academy of Pediatrics and the Center for Disease Control. We will expect your cooperation in following our recommendations for immunization.

Our practice firmly believes in immunizing children. A child that is not immunized puts others at risk, especially newborns. We simply cannot jeopardize the health of our patients. We will be happy to work with you to space the immunizations during a reasonable period of time, but the attached guidelines must be adhered to reasonably.

If you have concerns about your child receiving recommended immunizations, we advise that you become educated to the diseases and their effects on the human body. A lot of false information has been generated so make sure you get the correction information. The Center for Disease Control has published immunization information as well as the American Academy of Pediatrics. Also the Texas Children's Hospital has a well-written book entitled "Vaccine-Preventable Disease: The Forgotten Story". Please make use of their information before making your decision. Web Sites are listed below for your assistance.

Sincerely,
Northwest Suburban Pediatrics, S.C.

www.immunizationinfo.org

www.vaccine.chop.edu

www.cdc.gov/vaccinesafetylindex.html

Please list all children in your household and indicate their immunizations status:

Please sign below. Your signature confirms that you:
• Received and understand the office immunization policy.
• You agree to immunize all the children in your household.
• The information provided above is accurate.

Thank You - immunizing our children keeps everyone safe!

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application