I understand that due to my occupational exposure to blood or other potential infectious materials, I may be at risk of acquiring Hepatitis B Viris (HBV) infection.

I have been provided with informaiton about the risks and benefits of vaccination against and have been offered the opportunity to ask questions I may have.

I decline the Hepatitis B vaccination at this time, I understand that 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 Hepatitis B vaccine, I can receive the vaccination series from my primary care physician.

I declient the vaccine, I understand that I may receive the vaccine at any time by contacting my primary care physician.