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Home
About
Services
Home Care
Companion Care
Enhanced Pediatric Care
Personal Care & Support
Home Infusion – IV Therapy
Blog
Service Areas
Careers
Forms
Contact
Schedule Appointment
HEPATITIS B VACCINE DECLINATION FORM
CONSENT:
Consent 1
Yes, I do want to have the vaccine. I hereby certify that I have fully read and understand the attached information regarding the administration of the Hepatitis B Vaccine series
Consent 2
I understand that due to my occupational exposure to blood or to other potentially infectious material, I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B Vaccine at no charge to myself, however, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccinate, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials, and I want to be vaccinated with the Hepatitis B Vaccine, I can receive the vaccine at no charge
Consent 3
I have already received the Hepatitis B Vaccine Series. The series of vaccines were completed on dates
Date 1
MM slash DD slash YYYY
Date 2
MM slash DD slash YYYY
Date 3
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