60 Niagara Street, 2nd Floor, Buffalo, NY 14202
 Phone: (716) 268-8705  Fax: (716) 589-2290
 

Influenza Declination Form


First Name:  Middle Name:  Last Name: Telephone # 

Date of Birth: - - Example: 02 23 1983            Age:  Gender:    
Address:   City:  State:   Zip Code: 
 

DECLINATION AND SIGNATURE

I DECLINE to be vaccinated against the influenza virus. I have had the opportunity to be vaccinated, but refused. I accept responsibility for my declination and risk of exposure. I agree to always wear a face mask provided to me by Broadway WNY Home Care while caring for my patient throughout the Flu season.
Employee Signature: 
Draw your signature in the box above. On a desktop or laptop computer, you can use a mouse (click and drag to draw). On a touch screen device, you can use a stylus or your finger.

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Date:

 

 


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