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Date
Month
Day
Year

Employee Consent to receive Seasonal Influenza Vaccine

I have read and understand a copy of the MI Influenza Vaccine Information sheet (Inactive or recombinant). I have had a chance to ask questions that were answered to my Satisfaction. I believe I understand the benefits and risk of the influenza vaccine and I request the vaccine to be administered to my by SMCF qualified staff.

Severe allergy to eggs
History of Guillian Barre Syndrome: (Hold if yes)
Pregnant: (Must see OBGYN for permission)

Employee declination to receive Seasonal Influenza Vaccine

I have read and understand a copy of the MI Influenza Vaccine Information sheet (Inactive or recombinant). I have had a chance to ask questions that were answered to my Satisfaction. I believe I understand the benefits and risk of the influenza vaccine and I decline the vaccine.

Employee Consent to receive Seasonal Influenza Vaccine

Personal Items

All resident’s personal items should go directly to the SMCF Laundry Department to be clearly labeled with their name upon admission.  Clothing will be marked in an inconspicuous place.  Unmarked items make it impossible to identify ownership and proper labeling will assure that your family member’s items remain safe with them.  Personal television sets are allowed and are properly set up by our Maintenance Department.

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