Name: Signal Health Group
Address: 10475 Crosspoint Blvd, Indianapolis, IN, 46256, US
Telephone: 800-953-6183
Price range: $$

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.
1. I have previously received the series of Hepatitis vaccine injections.
2. I have been determined to have antibodies against Hepatitis B.
3. I shouldn’t have the Hepatitis B vaccine due to medical reasons.
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.
Print Name:
Employee Signature:
Date:

Request or Decline the Hepatitis B Vaccine