Vaccinations Form Name * Role * VACCINES RECEIVED I have received the following vaccinations and will provide documentation to the Clinical Manager now. please check all that apply Hepatitis B MMR Flu COVID-19 (none, I decline all of the above vaccines) VACCINES DECLINED Declination Statement: I, the undersigned, acknowledge that I have been informed about the recommended vaccinations for Hepatitis B, Measles, Mumps, Rubella (MMR), Influenza (Flu), and COVID-19. I understand the potential risks of not receiving these vaccinations, including the increased risk of contracting and spreading infectious diseases. Despite this information, I choose to DECLINE the following vaccines: Hepatits B MMR Flu COVID-19 (none, I have received all the above vaccines) Acknowledgment: I acknowledge that by declining the vaccinations, I may be at increased risk for contracting and spreading illness and I agree to take necessary precautions to protect my health and the health of others. Reason for Declination (optional): SIGNATURE I certify that the information above is true and correct. * Please type your full name Date * MM DD YYYY Thank you! Your response has been sent to the Clinical Manager.
