Vaccinations | BRIGHT FUTURE

Recommended Vaccinations

Acceptance / Declination Form

I have been informed regarding the availability and advisability of receiving the following vaccinations: Hepatitis B (3-injection series}, Pertussis, Varicella and Influenza

Please check your choice to receive or decline the following:

Hepatitis B (3-injection series):

I do not wish to receive the Hepatitis B vaccination at this time. Should I change my mind, I will furnish proof to Bright Future for the Children of my vaccination.

I do wish to receive the series of three Hepatitis B immunizations (one, two and six months apart). I will furnish proof to you of any vaccinations.

Pertussis:

I do not wish to receive the Pertussis vaccination at this time. Should I change my mind, I will furnish proof to Bright Future for the Children of my vaccination.

I do wish to receive the Pertussis vaccination. I will furnish proof to you of any vaccinations.

Varicella:

I do not wish to receive the Varicella vaccination at this time. Should I change my mind, I will furnish proof to Bright Future for the Children of my vaccination.

I do wish to receive the Varicella vaccination. I will furnish proof to you of any vaccinations.

Influenza:

I do not wish to receive the Influenza vaccination at this time. Should I change my mind, I will furnish proof to Bright Future for the Children of my vaccination.

I do wish to receive the Influenza vaccination. I will furnish proof to you of any vaccinations.

Your Full Name

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Your Signature

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