Non Employee Other Designation Form

This form is meant for non-Atrium Health employees.

If you are an Atrium Health teammate, use the Vaccine Exemption/Other Form.

Your Information

First Name Last Name Your Contact Phone # Your Email Address Department Name Last 4 Digits of your Social Security Number

Vaccine Type You Are Submitting for Documentation Received Influenza vaccine from Atrium Health Physician Practice or from source outside of Atrium Received Covid-19 vaccine from Atrium Health Physician Practice or from source outside of Atrium

Date Vaccination Received: Date 2nd Vaccination Received: Please attach proof of vaccination. Tip: You may upload a photo from your phone or mobile device.

Non Employee Other Designation Form

Your Information

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