Please bring this form with you for Grades K through 5 .
Please print out this form and complete the History (Part A) before you bring your child for a physical exam. (6th grade and older)
Due to the time involved in the increasing number and complexity of forms that we are requested to complete, there is now a $10 fee for form completion. A form for school, sports or camp will be completed within 3 business days provided your child has had a complete physical examination within the past year. There may be an additional fee if you need the form completed in less than 72 hours. Forms may be picked up when ready or we can mail them to you with a self-addressed stamped envelope.
On each of the form pages please make sure to enter your child’s first and last name and date of birth.
If you require a New Jersey State Universal form (age 11 and up), we need to have the completed Part A questionnaire, as we must review it when we complete Part B (the Physical Form). If you need a copy of this form, it can be downloaded from our website.
Middletown Pediatrics Vaccine Policy Statement
We firmly believe in the effectiveness of vaccines to prevent serious illness and to save lives.
We firmly believe in the safety of our vaccines.
We firmly believe that all children and young adults should receive all of the recommended vaccines according to the schedule published by the Centers for Disease Control and the American Academy of Pediatrics.
We firmly believe, based on all available literature, evidence and current studies, that vaccines do not cause autism or other developmental disabilities.
We firmly believe that thimerosal, a preservative that has been in vaccines for decades and remains in some vaccines, does not cause autism or other developmental disabilities.
We firmly believe that vaccinating children and young adults may be the single most important health-promoting intervention we perform as health care providers, and that you can perform as parents/caregivers. The recommended vaccines and their schedule given are the results of years and years of scientific study and data gathering on millions of children by thousands of our brightest scientists and physicians.
These things being said, we recognize that there has always been and will likely always be controversy surrounding vaccination. Indeed, Benjamin Franklin, persuaded by his brother, was opposed to smallpox vaccine until scientific data convinced him otherwise. Tragically, he had delayed inoculating his favorite son Franky, who contracted smallpox and died at the age of four, leaving Ben with a lifetime of guilt and remorse. Quoting Mr. Franklin’s autobiography:
In 1736 I lost one of my sons, a fine boy of four years old, by the smallpox …I long regretted bitterly, and still regret that I
had not given it to him by inoculation. This I mention for the sake of parents who omit that operation, on the supposition
that they should never forgive themselves if a child died under it, my example showing that the regret may be the same
either way, and that, therefore, the safer should be chosen.
The vaccine campaign is truly a victim of its own success. It is precisely because vaccines are so effective at preventing illness that we are even discussing whether or not they should be given. Because of vaccines, many of you have never seen a child with polio, tetanus, whooping cough, bacterial meningitis, or even chicken pox, or known a friend or family member whose child died of one of these diseases. Such success can make us complacent or even lazy about vaccinating. But such an attitude, if it becomes widespread, can only lead to tragic results. Over the past several years many people in Europe have chosen not to vaccinate their children with the MMR vaccine after publication of an unfounded suspicion (later retracted) that the vaccine caused autism. As a result of under immunization, there have been small outbreaks of measles and several deaths from complications of measles in Europe over the past several years. Furthermore, by not vaccinating your child you are taking selfish advantage of thousands of others who do vaccinate their children. We feel such an attitude to be self-centered and unacceptable.
We are making you aware of these facts not to scare you or coerce you, but to emphasize the importance of vaccinating your child. We recognize that the choice may be a very emotional one for some parents. We will do everything we can to convince you that vaccinating according to the schedule is the right thing to do. However, should you have doubts, please discuss these with your health care provider in advance of your visit. In some cases, we may alter the schedule to accommodate parental concerns or reservations. Please be advised, however, that delaying or “breaking up the vaccines” to give one or two at a time over two or more visits goes against expert recommendations, and can put your child at risk for serious illness (or even death) and goes against our medical advice as providers at Middletown Pediatrics.. Such additional visits may require additional copays on your part. Furthermore, please realize that you will be required to sign a “Refusal to Vaccinate” acknowledgement in the event of lengthy delays.
Finally, if you should absolutely refuse to vaccinate your child despite all our efforts, we will ask you to find another health care provider who shares your views. We do not keep a list of such providers, nor would we recommend any such physician.
Please recognize that by not vaccinating you are putting your child at unnecessary risk for life threatening illness and disability, and even death.
As medical professionals, we feel very strongly that vaccinating children on schedule with currently available vaccines is absolutely the right thing to do for all children and young adults. Thank you for your time in reading this policy, and please feel free to discuss any questions or concerns you may have about vaccines with anyone of us.