Model certificate of refusal of vaccination to free download

If the benefits of vaccination are not in doubt at the level of society, everyone is free to choose whether or not to be vaccinated. This is still a matter of individual responsibility and freedom.

The question is topical because of the Covid-19 pandemic and the concerns about the serious side effects of the vaccine from AstraZeneca:

  • Blood clots (thrombosis),
  • High fever,
  • Body aches,
  • Headache,
  • Dyspnea (difficulty breathing).
Example of a certificate of refusal to be vaccinated
Download a letter of refusal for vaccination

If you do not want to be vaccinated or want to refuse a particular vaccine, the safest way to ensure that your wishes are respected is to prepare and sign a letter of refusal to be vaccinated and give it to someone you trust or to your doctor.

Sample letter of refusal of vaccination

<First and last name>

Subject: refusal of vaccination

I, the undersigned <Name and surname>, born on <Date of birth> in <City of the place of birth> and residing at <Address, zip code, and city of present residence> have read the benefits and risks of the vaccine <Name of vaccine> against Covid-19 and declare that I do not wish to be injected with this vaccine (<Name of vaccine>).

<City>, on <Date of day>,

<Name and first name>,


To use and personalize this model of certificate of refusal of vaccination, you just have to make a ” Copy & Paste ” of the text of this article in your word processor (Microsoft Word ou Writer d’Open Office). You can also download our free template in PDF format here: certificate refusal of vaccination – PDF Format.

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Specialist in finance and taxation from my professional activity and university formation, I share my knowledge and experience on the Juristique website. I regularly publish economic indexes such as SYNTEC index, BT01, ILAT, construction and rent reference indexes, and banking tools like SWIFT Codes or CNAPS Codes for international wire transfers.

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