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Current Resident
Employee
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Name
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First
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Your Name
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First
Last
Resident Name
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First
Last
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Please select your care center, or the center where your loved one resides
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Select One
Garden Court Health and Rehabilitation Center - Bossier City, LA
Heritage Manor of Bossier - Bossier City, LA
Heritage Manor Health and Rehabilitation Center - Ferriday, LA
Health Center at Brentwood - Lecanto, FL
Heritage Manor of Franklinton - Franklinton, LA
Coastal Health and Rehabilitation Center - Gulfport, MS
Courtyard Rehabilitation and Healthcare - McComb, MS
Glenburney Health Care and Rehabilitation Center - Natchez, MS
Greenbough Health and Rehabilitation Center - Clarksdale, MS
Hilltop Manor Health and Rehabilitation Center - Union, MS
The Oaks Rehabilitation and Healthcare Center - Meridian, MS
Ocean Springs Health and Rehabilitation Center - Ocean Springs, MS
Pass Christian Health and Rehabilitation Center - Pass Christian, MS
Pine View Health and Rehabilitation Center - Waynesboro, MS
Starkville Manor Health Care and Rehabilitation Center - Starkville, MS
Winona Manor Health Care and Rehabilitation Center - Winona, MS
Cardinal Healthcare and Rehabilitation Center - Lincolnton, NC
Cary Health and Rehabilitation Center - Cary, NC
Clay County Care Center - Hayesville, NC
Emerald Ridge Rehabilitation and Care Center - Asheville, NC
Forrest Oakes Healthcare Center - Albemarle, NC
Gateway Rehabilitation and Healthcare - Lenoir, NC
Hunter Woods Nursing and Rehabilitation Center - Charlotte, NC
Oak Grove Healthcare Center - Rutherfordton, NC
The Oaks at Sweeten Creek - Arden, NC
Transitional Health Services of Kannapolis - Kannapolis, NC
Valley View Care and Rehabilitation Center - Andrews, NC
Walnut Cove Health and Rehabilitation Center - Walnut Cove, NC
Wellington Rehabilitation and Healthcare - Knightdale, NC
Westwood Health and Rehabilitation Center - Archdale, NC
Willowbrook Rehabilitation and Care Center - Yadkinville, NC
Wilora Lake Healthcare Center - Charlotte, NC
Siemon's Lakeview Manor Nursing and Rehabilitation Center - Somerset, PA
Siemon’s Heritage Personal Care Center - Somerset, PA
Locust Grove Retirement Village - Mifflin, PA
Luther Ridge at Seiders Hill - Pottsville, PA
The Manor at Penn Village - Selinsgrove, PA
Pennknoll Village - Everett, PA
The Manor at St. Luke Village - Hazelton, PA
The Pavilion at St. Luke Village - Hazelton, PA
Ashland Nursing & Rehabilitation Center - Ashland, VA
Augusta Nursing and Rehab Center - Fisherville, VA
Grayson Rehabilitation and Health Care Center - Independence, VA
Kings Daughters Community Health & Rehab - Staunton, VA
Newport News Nursing and Rehabilitation Center - Newport News, VA
Consulate Health Care of Norfolk - Norfolk, VA
Pheasant Ridge Nursing and Rehab Center - Roanoke, VA
Skyline Nursing and Rehabilitation Center - Floyd, VA
Consulate Health Care of Williamsburg - Williamsburg, VA
Consulate Health Care of Windsor - Windsor, VA
Consulate Health Care of Woodstock - Woodstock, VA
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Family Member Permission
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I have permission to accept or refuse the Bivalent Booster on behalf of the resident listed above
Agreement to take the COVID-19 Bivalent Booster
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I agree to take the vaccine booster
I refuse to take the vaccine booster
We're currently only offering the COVID-19 Bivalent Booster to Residents and Employees.
Agreement for your loved one to take the COVID-19 Bivalent Booster
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I agree for my loved one to take the vaccine booster
I refuse for my loved one to take the vaccine booster
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Family Member Contact Information
Email
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Phone
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We're sorry to hear that you have no interest in taking this new booster. Please let us know why below and submit your response.
We're sorry to hear that your loved one has no interest in taking this new booster. Please let us know why below and submit your response.
Comments / Questions?
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Confirmation
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I acknowledge that this form is only to request an appointment and that an appointment is not guaranteed
Confirmation (copy)
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I agree to be contacted by the center to schedule a time/date to have the vaccine booster administered once the appointment is confirmed
Confirmation (copy) (copy)
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Once the appointment is confirmed, I will bring documentation to show I (or my loved one) have taken the COVID-19 vaccine and are up-to-date on booster shots
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