Hepatitis B Vaccine Notification Form

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

I have been given the opportunity to be vaccinated with the Hepatitis B vaccine. I understand that I will pay for all three injections.

• I decline the Hepatitis B vaccination at this time.
• Yes, I wish to be vaccinated against Hepatitis B.
• I have already received the Hepatitis B vaccine.