Services
Personal Care
Memory Care
Long-term Care
Recovery to Home
Nazareth At Home
Nazareth Elite Concierge
Spiritual Care
Independent Living
About
Schedule a Tour
Volunteer
Activities & Stories
In the News
Who We Are
Nazareth Homes Foundation
Resources
50th Anniversary RSVP
Caregiver Support Group Lunch & Learn
Community Education & Resources
Careers
Careers at Nazareth
Contact Us
Services
Personal Care
Memory Care
Long-term Care
Recovery to Home
Nazareth At Home
Nazareth Elite Concierge
Spiritual Care
Independent Living
About
Schedule a Tour
Volunteer
Activities & Stories
In the News
Who We Are
Nazareth Homes Foundation
Resources
50th Anniversary RSVP
Caregiver Support Group Lunch & Learn
Community Education & Resources
Careers
Careers at Nazareth
Contact Us
Services
Personal Care
Memory Care
Long-term Care
Recovery to Home
Nazareth At Home
Nazareth Elite Concierge
Spiritual Care
Independent Living
About
Schedule a Tour
Volunteer
Activities & Stories
In the News
Who We Are
Nazareth Homes Foundation
Resources
50th Anniversary RSVP
Caregiver Support Group Lunch & Learn
Community Education & Resources
Careers
Careers at Nazareth
Contact Us
Services
Personal Care
Memory Care
Long-term Care
Recovery to Home
Nazareth At Home
Nazareth Elite Concierge
Spiritual Care
Independent Living
About
Schedule a Tour
Volunteer
Activities & Stories
In the News
Who We Are
Nazareth Homes Foundation
Resources
50th Anniversary RSVP
Caregiver Support Group Lunch & Learn
Community Education & Resources
Careers
Careers at Nazareth
Contact Us
Take a Tour
Give
Take a Tour
Give Now
Employee Influenza Vaccine Consent - No Insurance
Nazareth Home Campus
*
Clifton
Highlands
Employee Name
*
First
Last
Employee Date of Birth
*
(mm/dd/yyyy)
Do you wish to receive the influenza vaccine according to the recommended schedule? (This vaccine is offered annually.)
*
Yes
No
Reasons for declining.
Already Received
Select
Date Received
Alergic
Select
Comment
Other
Select
Comment
I have read the CDC informational handout, have been given the opportunity to ask questions, and understand the flu information provided. This facility and its employees will not be held responsible for any adverse reactions to this vaccine now or in the following years. Local site reactions are expected in 5-10% of vaccine recipients. Less than 1% of vaccines have reported slight elevations of body temperature but severe allergic reactions have not been documented.
CDC Flu Shot Information Sheet
Signature
*
Date
*
Δ
