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Ace Home Care Charlotte — Influenza Vaccine Informed Consent
Annual Influenza Vaccine Informed Consent / Declination Form.
Ace Home Care Charlotte
6015 Delta Crossing Ln Apt C, Charlotte, NC 28212
info@acehomecarecharlotteinc.com
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Email
*
Your email
Vaccine Decision
Employee Full Name
*
Your answer
Decision
*
I ACCEPT — I request that this vaccine be given to me.
I REFUSE — I decline the offer of vaccination this year.
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