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Flu Vaccine Appointment Request Form

I am a(n) *

Current Resident
Employee
Family Member (on behalf of resident)
None of the above

Name *

First

Last

Your Name *

First

Last

Resident Name *

First

Last

__________________________________________________

Please select your care center, or the center where your loved one resides *

__________________________________________________

Family Member Permission *

I have permission to accept or refuse the Flu Vaccine on behalf of the resident listed above

Agreement to take the Flu Vaccine *

I agree to take the Flu Vaccine
I refuse to take the Flu Vaccine

We're currently only offering the Flu Vaccine to Residents and Employees.

Agreement for your loved one to take the Flu Vaccine *

I agree for my loved one to take the Flu Vaccine
I refuse for my loved one to take the Flu Vaccine

__________________________________________________

Family Member Contact Information

Email *

Phone *

__________________________________________________

We're sorry to hear that you have no interest in taking the Flu Vaccine this year. Please let us know why below and submit your response.

We're sorry to hear that your loved one has no interest in taking the Flu Vaccine this year. Please let us know why below and submit your response.

Comments / Questions?

__________________________________________________

Confirmation *

I acknowledge that this form is only to request an appointment and that an appointment is not guaranteed

Confirmation (copy) *

I agree to be contacted by the center to schedule a time/date to have the Flu Vaccine administered once the appointment is confirmed

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