Download Hepatitis B Form

DenTemp Staffing, Inc.
Proud To Serve The Dental Community
Assistants
. Hygienists . Receptionists . Office Managers and Front Office Personnel
Hepatitis B Vaccine
DenTemp Staffing, Inc. can only employ dental professionals who have received or have
declined the Hepatitis B vaccine. Please complete this form with the information requested.
_____ Yes, I already received the hepatitis B vaccine. I understand that it is my responsibility to
forward a copy of my medical records as proof I have received the vaccine.
______ No, I have not received the Hepatitis B vaccine. . 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) infection. I understand that I may decide to have the Hepatitis
B vaccine at a later date; it is my responsibility to forward a copy of my medical records to
DenTemp Staffing, Inc.
Print name: ________________________ Signature_____________________ Date________
Phone (470) 207-0100 | Fax (844) 340-2744 | Email: [email protected]
www.dentempus.com