Rehabilitation, Skilled Nursing, & Memory Care: 757-420-2512   ·   Assisted Living: 757-282-2384

Rehabilitation, Skilled Nursing,
& Memory Care: 
757-420-2512
Assisted Living: 757-282-2384

COVID-19 Vaccine Information and Forms

Great news – the COVID-19 vaccine is coming to Beth Sholom Village! The first dose of the two-step vaccine will be administered during our CVS clinic on January 2, 2021. The second dose of the vaccine will be administered during the CVS clinic on January 23, 2021! To protect our residents, we will need a completed Intake Consent Form for each resident. Please see the instructions below for completing and submitting the necessary form for your loved one. We MUST have the completed consent form back to Beth Sholom Village by December 23, 2020. We appreciate your swift response to our request.

Instructions for completing and returning the COVID-19 Vaccine Responsible Party Consent Form:

  1. Open and review the COVID-19 Vaccine Responsible Party Consent Form
  2. Fill in the consent form on your computer or smartphone
  3. Options for delivering the completed form to Beth Sholom Village:
    1. Save the completed PDF COVID-19 Vaccine Responsible Party Consent Form to your computer
      • E-mail completed document to Marcia Brodie: Mbrodie@bethsholomvillage.com
      • The subject line should say “Vaccine Consent form for (resident name)”
      • Attach form to e-mail and send
    2. Print out the completed PDF COVID-19 Vaccine Responsible Party Consent Form
      • Mail the form to Beth Sholom Village c/o Marcia Brodie: Vaccine 6401 Auburn Drive Virginia Beach, VA 23464
    3. Print out the completed PDF COVID-19 Vaccine Responsible Party Consent Form
      • Deliver in an envelope marked “ ATTN: Marcia Brodie” to the front door of Beth Sholom Village at 6401 Auburn Drive Virginia Beach, VA 23464
    4. Print out the completed PDF COVID-19 Vaccine Responsible Party Consent Form
      • Using a smartphone, take a clear picture of the completed document
      • E-mail it to Marcia Brodie: mbrodie@bethsholomvillage.com
      • The subject line should say “Vaccine Consent form for (resident name)”
      • Attach photo to e-mail and send

Forms and Additional Information