Flu Declination

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Declination of Influenza Vaccination

Worldwide Medical Services has recommended that I receive influenza vaccination to protect the patients I serve’; I acknowledge that I am aware of the following facts:
  • Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
  • Influenza vaccination is recommended for me and all other healthcare workers to protect this facility’s patients from influenza, its complications, and death.
  • If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.
  • If I become infected with influenza, I can spread severe illness to others even when my symptoms are mild or non existent.
  • I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t change, my immunity declines over time. This is why vaccination against influenza is recommended each year.
  • I understand that I cannot get influenza from the influenza vaccine.
  • The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including:
    • all patients in this healthcare facility
    • my coworkers
    • my family
    • my community
  • I agree to wear a mask in all patient care areas. Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons:
I understand that I can change my mind at any time and accept influenza vaccination, if vaccine is still available. I have read and fully understand the information on this declination form.
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  • (480) 467-4443
  • info@wwmedical.com

  • 3451 South Mercy Road
    Gilbert, AZ 85297


Monday – Friday 8:00a – 5:00p
Saturday & Sunday Closed