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Cuffley & Goffs Oak Medical Centre NHS GP Surgery in Hertfordshire

Childhood immunisation disclaimer

Childhood Immunisation Disclaimer

Section

I decline consent to the following immunisation(s): *

6in1: Diphtheria, Tetanus, Pertussis, Polio, Hib and Hepatitis B

Haemophilus Influenzae Type B and Meningitis C

Meningitis ACWY

Meningitis B

MMR (Measles, Mumps and Rubella)

Pneumococcal

Pre-school booster: Diphtheria, Tetanus, Pertussis and Polio

Rotavirus

Seasonal Influenza

Statement of parent or guardian

Declaration *

I do not consent to my child receiving protection against the diseases indicated. I have been fully advised and understand about the risks of declining these immunisations. I am aware that I can change my mind at any time and there is no upper age limit for immunisation.

If you are human, leave this field blank.

Cuffley Village Surgery
Maynard Place
Cuffley
Herts
EN6 4JA

Get directions

01707 875201

Valley View Health Centre
Goffs Lane
Goffs Oak
Herts
EN7 5ET

Get directions

01707 875223

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