Influenza Information - Nightingale Care

It is our agency policy to collect Influenza Vaccine information annually. Please read the information below.

If you DECLINE the flu vaccine, please complete and submit the form below by December 1, 2023.

If you have received the flu vaccine, please send a copy of your vaccine record to the agency by December 1, 2023.

Please click here for information on Influenza (required reading):

Flu-Vaccination-DataSnapshot-2023_0 Download

Flu Vaccine Declination

Name(Required)

First Last

Date

I receievd the Influenza Vaccine on the date below and will send my card to the office:

I have read the Influenza Vaccine Information Sheet and I have chosen not to receive the Influenza Vaccine. My reason for not receiving the vaccine is as follows:

Digital Signature: