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I am a(n)
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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
Baya Pointe Nursing and Rehabilitation Center - Lake City, FL
Deltona Health Care - Deltona, FL
Evans Health Care - Fort Myers, FL
Fletcher Health and Rehabilitation Center - Tampa, FL
Grand Oaks Health and Rehabilitation Center - Palm Coast, FL
Green Cove Springs Rehabilitation and Care Center - Green Cove Springs, FL
Habana Health Care Center - Tampa, FL
Harts Harbor Health Care Center - Jacksonville, FL
Heron Pointe Health and Rehabilitation - Brooksville, FL
Island Health and Rehabilitation Center - Merritt Island, FL
Raydiant Health Care of Jacksonville - Jacksonville, FL
Lake Mary Health and Rehabilitation Center - Lake Mary, FL
North Florida Rehabilitation and Specialty Care - Gainesville, FL
Raydiant Health Care of North Fort Myers - North Fort Myers, FL
Oaktree Healthcare - South Daytona, FL
Raydiant Health Care of Orange Park - Orange Park, FL
Osprey Point Nursing Center - Bushnell, FL
Parks Healthcare and Rehabilitation Center - Orlando, FL
San Jose Health and Rehabilitation Center - Jacksonville, FL
Vista Manor - Titusville, FL
Wedgewood Healthcare Center - Lakeland, FL
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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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