Hepatitis Form

Hepatitis B Immunization Acceptance or Declination

I, understand that due to my occupational exposure to bloodborne pathogens and other potentially infectious materials, I might be at risk of acquiring Hepatitis-B virus (HPV) infection. I have been given the opportunity to be immunized with the Hepatitis-B vaccine, free of charge.

I choose to accept immunization with the Hepatitis-B vaccine at this time. If I have previously had a Hepatitis-B vaccination series, I may be required to have an antibody titer drawn prior to vaccination to determine need for vaccine.
I choose to decline immunization with the Hepatitis-B vaccine at this time.

I understand that by declining this vaccine I continue to be at risk of acquiring Hepatitis-B and, if contracted, there is a risk of chronic disease, liver cirrhosis, liver cancer or death. If in the future, I continue to have occupational exposure to blood or other potentially infectious materials and I want to be immunized to Hepatitis-B, I can receive a vaccination series at no charge.