Office forms »

Vaccine Policy

Please fill out this form as completely as possible. It will be sent securely to our office.

At Fairhope Pediatrics we firmly believe:

  • Vaccines prevent serious illnesses and save lives.
  • Vaccines are safe and do not cause developmental delays or autism.
  • Our patients should receive all vaccines according to the schedule recommended by the American Academy of Pediatrics and the Centers for Disease Control.
  • Vaccinating our patients is one of our most important jobs.

To remain a patient in good standing with Fairhope Pediatrics, you agree to:

  • Comply with the vaccines listed in the current CDC schedule and recommended by your Fairhope Pediatrics providers. This includes diphtheria, hepatitis A, hepatitis B, Hib, HPV, meningococcal, MMR, pertussis, pneumococcal, polio, rotavirus, tetanus, and varicella. Fairhope Pediatrics does not provide personal exemptions from vaccination.
  • Comply with the vaccine schedule recommended by the CDC, AAP, and your Fairhope Pediatrics provider. Comply with the CDC catch up schedule if your child is behind on vaccines. Fairhope Pediatrics does not delay, space out, or skip vaccines.
  • Accept financial responsibility for any vaccine that you have consented to for your child once that vaccine has been prepared by Fairhope Pediatrics staff, whether or not the vaccine dose is completed. Refusal or failure to cooperate with the vaccine will result in a charge to your child’s account equal to the CDC Private Sector price (available on request) plus a 20% service fee due at time of service.

  • Signature

    By signing below you agree and acknowledge compliance with this policy.
  • Hidden
    MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.