Dear Family, Health Care Proxy, Responsible Party,

As promised, enclosed is the COVID-19 vaccine consent form and fact sheet.  Please review the information carefully.  You may complete the consent form electronically, sign and return via email to  Or you may print the consent form, fill out by hand and return via confidential fax (585-461-9833) or bring the signed consent to the drop box located at the Kirkhaven entrance.  The insurance information section of the form is not needed for residents.

The vaccine is not mandatory.  However, if you know you want your loved one to receive the vaccine, you must give consent as soon as possible in order to be included in the first vaccine clinic (date to be determined soon.)  Once we confirm the number of residents and staff interested in receiving the vaccine, the pharmacy will schedule the three (3) vaccine clinics at Kirkhaven.

In an effort to simplify this process and promote vaccine administration at our facility as soon as possible, Kirkhaven nursing team members will be calling responsible parties today and tomorrow to confirm vaccine information was received, answer any questions and to obtain verbal consent.  If you provide verbal consent you do not need to sign the written form.

If you have questions about the vaccine or vaccination process you may call our Infection Prevention Professional, Christine Schroeder, RN at 585-461-1991 ext. 3057 or email


COVID-19 Vaccine Fact Sheet

COVID-19 Vaccine Consent Form