Forms:
Immunization Requirements Form![]()
LCC must receive copies of the blood titer results. Booster immunizations may be needed if not showing immunity.
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Physical Form![]()
Please ask your physician to fill out the form entirely and place the facility stamp at the bottom of the form.
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Influenza Statement of Refusal Form

influenza_statement_of_refusal.doc | |
File Size: | 121 kb |
File Type: | doc |
Hepatitis B Declination Form

hep_b_statement_of_refusal.doc | |
File Size: | 118 kb |
File Type: | doc |
Tdap Declination Form

tdap_statement_of_declination.doc | |
File Size: | 118 kb |
File Type: | doc |
Please print out and sign the attached form if you'd like to decline the Tdap vaccination. (LCC can provide a printed copy as well.)