Electronically sign your request:
By entering the following electronic signature you attest to the following statement:
I have been offered, at no charge, the annual flu vaccine; however, I wish to decline vaccination. I may reverse this decision at any time during the current season by contacting No Place Like Home and requesting vaccination provided that the vaccine is still available at such time.
Date of birth:
Professional license #:
(your RN, LPN, or CNA license)
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