This form is meant for non-Atrium Health employees.

If you are an Atrium Health teammate and received your influenza vaccine from an outside provider such as a retail pharmacy or any personal physician’s office (Atrium Health or other primary care provider), use the Influenza Vaccine Exemption and Other Designation eForm.

The Atrium Health Flu Campaign starts Monday, September 27th. All teammates must comply with Atrium Health Policy Infectious Diseases Prevention Policy HR-4.05 by November 1st.

Use this form if you are not an Atrium Health employee and received your vaccine from outside of the Atrium Health Teammate Health program, like your Atrium Health personal provider, a retail pharmacy or other outside physician.

Teammates must fill out this electronic form to demonstrate proof of compliance. The document you submit must contain type of flu vaccine, manufacturer, lot number and expiration date. Upon submission, you will receive a badge sticker to demonstrate your compliance.

Your Information

Contact Information

Vaccine Information