So, you’ve signed the Refusal to Vaccinate document?

Refusal to Vaccinate form header - sm 2Perhaps you missed DO NOT SIGN the “Refusal to Vaccinate” Form and unwittingly signed the form!

What to do next?

Start by asking for the original back. Tell the doctor (or whoever) that your “family” decided for many reasons (we came up with 12) that it was not good to have it in your (or your child’s) file. It is best not to offer any more information than that or engage in any discussion, but to remain firm but pleasant. When it comes to vaccines, anything you tell them can be used against you, believe it or not!

The doctors have been warned that if they don’t have this form on file, the parent could sue the doctor should the child get one of the diseases the vaccine was ‘supposed’ to prevent. The lawyers for the vaccine agenda have pitted the doctors against the health and safety of their patients. Sad, huh? We have proof of this because we’ve read the instruction page that accompanied the Refusal to Vaccinate form that was given to physicians, et al.

If the doctor’s office does not cooperate, you will have to send them a certified letter “rescinding your signature” thus nullifying the form. It is also recommended that you send them a Vaccination Notice to end all disputes regarding vaccines.

Here is a sample letter reflecting what I would write:

Dear Doctor Bloohoo,

Unfortunately, I mistakenly signed the Refusal to Vaccinate form regarding my son (or daughter) that your office asked me to sign. After discussion with my family, I have decided that this form was not in our best interest to sign and have placed in my son’s (or daughter’s) file.

I hereby rescind my signature on that form making it null and void and require that your office return the original to me.

I (we) have concluded, after much research, that vaccinations today are neither safe nor effective and that the theory of “herd immunity” has been scientifically proven invalid many times.  So I am sending you my (our) own Vaccination Notice. Please include this notice in my son’s (or daughter’s) medical record.


Jane Doe (Mother of Sally Doe)
125 Maple Canyon
Canton, Ohio

Enclosed: Vaccination Notice

The Vaccination Notice instructions and link can be found on this page.


56 responses to “So, you’ve signed the Refusal to Vaccinate document?

  1. What if you just switch doctors and ask for your child’s file instead of it being faxed to your new doctor, would you be able to get the originals that way, or do they keep a copy of all records for themselves?


  2. When did this “refusal to vaccinate” form first come out? I don’t think I signed it. I have 4 children 2 vaccinated (although not up to date) and 2 unvaccinated.


    • The form states it was copyrighted in 2013 and revised in 2014.

      It might be optional for physicians. Although it is strongly recommended by the American Academy of Pediatrics.


      • I know i used to sign a few for my 5 year old, but they looked different then, and i used to make few simple changes on it with my initials before signing it. This new one is recent.


  3. I signed this for my eldest after much badgering and pushing from the pediatrician’s staff. It was in FL and we now live in TX could i call and mail this form? Or would something else be better?


  4. What form do we send or give to the pediatrician then? I’m not sure my daughter signed this form she just had a baby.


  5. Pingback: DO NOT SIGN the Refusal to Vaccinate form! | Parents Against Mandatory Vaccines

  6. What should one do if every doctor in the area requires this form to be signed. I’ve called all Peds in our area and they all required this to be signed in order to be a patient who doesn’t receive vaccinations.


    • If you call them on the phone, that is what their office employees have been told to say. You don’t need to go for “well visits”. They are a scam. So, wait until your child has a broken bone or something and use the Vaccination Notice for Physicians.


    • Another option is to use a family practice doctor instead of a pediatrician. Family practice doctors are often less insistent on vaccination than pediatricians.


  7. What if you sogned it because it was required for your child to go to school here in tx? I didnt have a doctor sign it just myself and the receptionist at the school.


  8. I can’t find the corporate name for Michigan Health Department on the Dun and Bradstreet website. Anyone know what it is?


  9. Is this applicable in California as well? I do not vaccinate but info remember signing that form.


  10. I remember signing something for my daughter in 2011. I am not sure if I did for my son. Should I ask when I go to visit? I have since then transfered to a chiropractor. Should I just send a letter.


  11. Thank you for this. I signed one of these for each of my kids. I am now freaking out, I feel so stupid for not reading between the lines. I was thinking of just sending this letter for each of them. Can I just mail it or fax it?


  12. Isn’t there an “edited” form somewhere stating we refuse to vaccinate but the statements have been reworded to say things such as vaccines are unsafe, etc? I know there is a letter, but was thinking there was a form somewhere too.


  13. I signed this form but not in the presence of anyone. In fact, it was never discussed at all until I called to ask for the original. When I told the practice that we had talked about it as a family and decided we did not want that form in our daughter’s file and that we would like the original back, the nurse gave me the run-around and the doctor attempted to dissuade me (this was an MD who had previously not pushed vaccination but has just joined a new group practice that requires this form). Before I proceed to the next step, I was wondering if giving them the Vaccination Notice would somehow validate the form that is currently valid since no one was there when I signed (and actually put more of a target on our family by so doing)? Is it better to leave things alone, or is it more important to get the original? Also, is it now too late in terms of a number being assigned to my child in a national vaccine database? In other words, is there now a tracking number assigned to her even if I get the original back?


    • Here is what I would do.

      I’d call them again and ask to speak to the office manager. I’d tell her/him:

      “I mistakenly signed a “refusal to vaccinate” form at your office’s request. The form contained statements by the American Academy of Pediatrics that I now know are not factual. Do you want to return the form or must I send you a signature revocation?”

      If they refuse, and offer some flimsy office policy, etc., I would thank them politely and hang up. I wouldn’t waste time in discussion. Then I would send them the Vaccination Notice and write on the top: This document supersedes the “Refusal to Vaccinate” form on file.
      Info regarding The Vaccination Notice:

      The Vaccination Notice also relieves them of liability from your suing them if your child suffers from complications should he/she contract one of the diseases they falsely claim the vaccine will protect them from. That is why physicians are told they MUST get parents who don’t vaccinate to sign this form. Some @$%& attorneys came up with this scheme.

      Good luck and thank you for protecting your child (children) from this insidious pharmaceutical nightmare.



  14. Hi AL,
    First off thank you for this website. It’s wonderful.

    Our son has had his first round of vaccines and we stopped afterwards based on our religious beliefs. We didn’t know until we spoke with our priest. So when I told our doctor we didn’t want to vaccinate anymore, she had me sign something comparable to this Refusal to Vaccinate form. I will ask for the original back and I will rescind my signature, but the examples of Vaccination Notice don’t mention anything about faith, it being more scientific/factual. We are also writing a letter for our son’s pre-school admissions paperwork, stating that we oppose vaccination based on our religious beliefs, as it is our right in New Jersey.

    I find that our letter to the school plus our explanation to the doctor based on faith is in contradiction with the factual Vaccination Notice, right? I am worried they will nullify our statement of faith if we send the Vaccination Notice.

    Or is it all ok and I should send the Notice anyways?

    Thank you.


  15. I had already signed several forms before realizing that it was not a good idea to do so. When I asked to have the original copies, I was told that they had all been “scanned into the system” and that the originals had already been then away. In this situation, what should I do to rescind and nullify the previous forms?


  16. Ok If I don’t sign the paper and I won’t vaccinate, then they won’t allow my children in school .. Where do I go from here, homeschooling? ?


  17. I just discovered this info so I ended up signing one at a 2 month app. I am pretty sure they had scanned it into the system. do I send them a recession and ask them to scan it? if yes how do I word it. can i ask them to delete it from the system? also my 4 month app is due soon so I just bring the notice for that?…. Im in texas and the hospital had called and told my husband that we haven’t been to a well visit , does that mean they are tracking my child? if we’ll visit is a scam why are they calling me telling me to go get one?


    • If it was me, I’d send the rescission letter with a Vaccination Notice.

      To our knowledge there is no statute requiring you to see a doctor when your son or daughter is well. The whole scam called “well baby visits” was set up to push vaccinations on unsuspecting parents and make more money for pediatricians.

      Public health employees in each state are now setting up vaccination tracking systems, which could explain why hospital employees called your home. There is no way they can force info from you. Just politely tell them your baby is doing great and you are too busy to talk.


  18. Isn’t the letter the Vaccination Notice? If so why would u put
    Enclosed: Vaccination Notice?


  19. Conservativemumof3

    I’ve sent this to my Dr well over a month ago thru certified mail and even enclosed a sase to send me the papers I signed under pressure for my 3 children . I have not heard anything and am thinking about calling but I want to be prepared when they say I can have my forms back what’s the right legal terms to use. Please help! Thank you


  20. I signed the refusal letter. I went back to the dr office and asked for it back but they said they already sent it in, and they wouldn’t give me the original back when I asked for it. Is there a way to get it out of the system once it’s scanned in? I’m in Texas. Do I just need to send in a recission letter and vaccination notice? Will that take care of it, or do I need to do something else? Will they send in the letter to the state that I’m resigning my signature and it’s null and void? Or will it forever be in the states system regardless?


  21. I unknowningly signed this form for my newest son. I called the doctors office and they will not remove it from the file..they say they can’t remove
    Anything. However, if I changed doctors I could request that papers not be sent in their file. Is that a good option?? I’ve been wanting to switch anyway.


  22. I am 33 weeks pregnant. And at my last two doctor visits I was asked if I wanted the tdap vaccine which they recommend for pregnant women to protect the baby against tetanus, diphtheria and pertussis. I refused the vaccine both times and was asked to sign a form stating I refused the vaccine. This was before I read this article so I signed them and now have two papers on file. Is this something I should be concerned about and try to get off file or should I not worry about it since the vaccines were intended for myself and not directly toward my baby. Thanks


  23. What is the next step I should take if the office refuses to scan in the letter rescinding my signature on the vaccine refusal forms?


  24. Hello, thank you so much for these helpful articles.
    I birthed my son at home, unassisted, meaning without the presence of a medical professional, so for several months his birth remained unreported. Really wish I would’ve kept it that way! When he was 3 months old though we began thinking that someday we’ll probably want to leave the U.S., and will need passports to do so. So, against my intuition I got him a birth certificate. When we went in to the gov building to sign the certificate, I was told I had to sign the vaccine refusal form. Unfortunately, I signed it and am now having quite a bit of regret and anxiety coming up… As a baby we once took him to a Naturopathic Doctor who is anti-vax and wonderful, and I never had to sign anything of the sort there. However the gov building has the original signed copy of the form and already electronically “sent it in”… I’m wondering if it’s worth trying to get it back / nullified, or if that would just attract attention to us? We are off-grid homesteaders, obviously anti-vax, intending to homeschool and remain very low-key under the radar out in the forest. We’re really not wanting to draw attention to us… Nowhere on any docs is our current address or phone number listed so I feel like it may be best to just let it be… What do you recommend?


  25. Hello,
    So last year I signed a refusal to vaccinate paper. I had no idea that it could be bad. I went back and asked for the original and the doctors office told me that they scan the papers and shred them and that everything is put into the computer. She told me they no longer had a paper copy. I spoke to the woman in charge at the time. She gave me a printed copy and the form said that I’m refusing certain shots at that time.
    When they followed up the same woman told me that she spoke to her supervisor and they told her that once something is in his records it can not be removed. Do you know if this is true?


  26. Hello. Thank you for this forum. I live in AL. I signed a form similar to the Refusal to Vaccinate at my local health department. It was formatted differently, but the language was the same. I was under the impression that it was required to receive the exemption certificates. Our children see a physician that respects our decision not to vaccinate. Should I attempt to obtain the original documents from the health department at this point? Would it be wise to submit a rescission letter and notice as well? Our family is planning to relocate to a different state in the near future.


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