Request or Decline the Hepatitis B Vaccine

Request or Decline the Hepatitis B Vaccine

* I hereby request the series of Hepatitis B Vaccinations
* I hereby decline the series of Hepatitis B vaccine injections.

* Please check the reason that you are declining the vaccination.




I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B Virus (HBV) infections. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine, at no charge to me; however, I decline the vaccination at this time. I understand that by declining this vaccine 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 series at no charge to me.