First Name / 名: (required 必填)

Last Name / 姓: (required 必填)

Date of Birth / 出生日期(月/日/年): (required 必填)

Aide Code / 護理編號: (required 必填)

By signing below, I acknowledge that I have received influenza vaccine information; I choose not to receive influenza vaccine. I agree to wear a surgical mask at all time while in area where clients may be present during Influenza season.

本人已收到流感疫苗質訊，本人選擇不接受流感疫苗。本人同意於流感季節期間，與客人相處時，全時間佩戴外科口罩

Signature / 簽名: (required 必填)