Please let us know by completing the following form.
I wish to decline the 2018 seasonal Influenza vaccine. *
I declare I have read and fully understand the information on this declination form. *
I am aware that not being vaccinated against Influenza may lead me to contract this disease while providing healthcare at Cabrini Health and my result in the transmission of this disease to others. *
I take full responsibility for this and will not hold the healthcare facility responsible. *
I acknowledge that by refusing to be vaccinated I am placing myself, my patients, my co-workers and my family at risk of contracting a vaccine preventable illness, which may have life threatening consequences. *
I have decided at this time to decline or defer vaccination and am aware that I can change my mind and accept the Influenza vaccine at a later date. *