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I am a(n)
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Current Resident
Employee
Family Member
None of the above
Name
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First
Last
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
Beneva Lakes Healthcare and Rehabilitation Center - Sarasota, FL
Beneva Lakes Assisted Living Center - Sarasota, FL
Brandon Health and Rehabilitation Center - Brandon, FL
The Brookshire - Melbourne, FL
Central Park Healthcare and Rehabilitation Center - Brandon, FL
Coral Bay Healthcare and Rehabilitation - W. Palm Beach, FL
Coral Trace Health Care - Cape Coral, FL
Englewood Healthcare and Rehabilitation Center - Englewood, FL
The Floridean Nursing and Rehabilitation Center - Miami, FL
Fort Pierce Health Care - Ft. Pierce, FL
Harbor Beach Nursing and Rehabilitation Center - Ft. Lauderdale, FL
Heritage Healthcare and Rehabilitation Center - Naples, FL
Hillcrest Health Care and Rehabilitation Center - Hollywood, FL
Kendall NSPIRE Healthcare - Kendall, FL
Keystone Rehabilitation and Health Center - Kissimmee, FL
Keystone Villas Assisted Living Center - Kissimmee, FL
Lauderhill NSPIRE Healthcare - Lauderhill, FL
Miami Lakes NSPIRE Healthcare - Haileah, FL
The Palms Rehabilitation and Healthcare Center - Palm Bay, FL
Plantation NSPIRE Healthcare - Plantation, FL
Plantation Bay Rehabilitation Center - St. Cloud, FL
Renaissance Health and Rehabilitation - W. Palm Beach, FL
Seaview Nursing and Rehabilitation Center - Pompano Beach, FL
Tamarac NSPIRE Healthcare - Tamarac, FL
Wood Lake Health and Rehabilitation Center - Greenacres, 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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