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Religious Exemption for Influenza Vaccination
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Medical Staff Services
Religious Exemption for Influenza Vaccination
Please complete the Religious Exemption form if your strongly held religious beliefs prevent you from getting the flu vaccine.
Teammate Name:
If Atrium Health Employee Contact Telephone Number:
I am requesting a religious exemption from receiving the seasonal influenza vaccine. As described below, my strongly held relgious beliefs prevent me from receiving the seasonal influenze vaccine. Please Provide a statement regarding your request:
I do hereby affirm that the above inforamtion reflects my strongly held religious beliefs and is true, accurange and complete.
I affirm the above information
I do not affirm the above information
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