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Pneumococcal & Influenza Consent

Marwood Nursing and Rehab|Documents and Links|Pneumococcal & Influenza Consent

Form 4 of 9

Note: Fields marked with an * indicates required field
Please indicate 'Yes' or 'No' for each of the following:

Yes

No

I, as the Resident / Responsible Person, have received and reviewed the educational materials for the Pneumococcal vaccination. *

Yes

No

I, as the Resident / Responsible Person, wish to receive the Pneumococcal vaccination. * If no, approximate date of last Pneumococcal vaccination:

Yes

No

I, as the Resident / Responsible Person, have received and reviewed the educational materials for the Influenza vaccination. *

Yes

No

I, as the Resident / Responsible Person, wish to receive the Influenza vaccination. * If no, approximate date of last influenza vaccination:

Yes

No

I, as the Resident / Responsible Person, have received and reviewed the educational materials for the PVC13 Pneumococcal vaccination.*

Yes

No

I, as the Resident / Responsible Person, wish to receive the Pneumococcal vaccination. * If no, approximate date of last Pneumococcal vaccination:

If signing on the Residents behalf, please provide the Resident's name in the Resident section.

Resident Name: *

Resident/Responsible Person Signature Name: *

Date: *

By submitting this Consent Form, please be aware that an electronic signature is as legally binding as a handwritten signature.

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