NOTICE OF REFUSAL OF CONSENT TO VACCINATION

1. The UK Government intends that there be a national vaccination campaign

against swine flu.
2. Under the Control of Disease (Public Health) Act 1984 – I have the right to
refuse my consent to vaccination.

Take Notice that I [Name] …………………………………………………………………………...

of [Address]………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………
hereby give notice to anyone to whom it may concern, that I REFUSE my consent to
vaccination against swine flu and hereby authorise, instruct and require that under no
circumstances am I to be vaccinated against swine flu as I exercise my right of freedom
of choice not to be vaccinated against swine flu.

I would be grateful if you would note your records to this effect.

Dated this Day of 2009

Signed

Print Name

Witnessed by

Signed

Print Name

Address

Occupation

Acknowledgment Of Receipt
I hereby acknowledge receipt of this notice of refusal of consent to vaccination

Signed

Print Name

Dated this Day of 2009