We the Parents/Guardians of ________________________________ (DOB: ____/_____/_____) have decided to immunize our child, but we would like to follow a vaccine schedule different from the standard schedule recommended by the AAP, the ACIP, and the Physicians/Nurse Practitioner of Jasper Pediatrics. We realize by following an alternative vaccine schedule our child may not be immunized or not fully immunized against the diseases the vaccines are designed to prevent. We also realize if our child is not immunized or fully immunized and he/she contracts one of the diseases, he/she could suffer long term permanent damage. This damage could include but is not limited to: Death, Permanent Neurologic Damage, Seizures, Developmental Delays, Motor Skill Problems, Paraplegia, Respiratory Issues, Feeding Issues, Contractures/Musculoskeletal Problems, Amputation of Extremities, Vision Problems, Blindness, Hearing Problems, Deafness and Learning Delays/School Problems.
The Physicians/Nurse Practitioner recommend the current schedule of immunizations be followed to best avoid the above mentioned complications and have advised the family that we do not recommend the use alternative vaccine schedule.
As the parents/guardian of ___________________________ (DOB :____/_____/______) we understand the risk of an alternative vaccine schedule and accept the risk.