Download Hepatitis B Vaccination Declination Form

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Transcript
Brenda Fitzgerald, MD, Commissioner | Nathan Deal, Governor
Olugbenga Obasanjo, M.D., Ph.D., M.P.H., M.B.A.
District Health Director
Glinda Scott, Henry Co. Environmental Health County Manager
137 Henry Parkway, McDonough, GA 30253
Phone: (770) 288-6190 www.district4health.org
District 4 Public Health
HEPATITIS B VACCINATION DECLINATION FORM
I, ______________________________________________________, understand that due to my
(Tattoo/Body Piercing Artist)
occupational exposure to blood or other potentially infectious materials, I may be at risk of
acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated
with Hepatitis B vaccine; however, I decline the Hepatitis B vaccination at this time. I knowingly
and willing assume the risk of any harm that I may experience as a result of my failure
to be vaccinated with Hepatitis B vaccine.
(TATTOO / BODY PIERCING ARTIST)
(BODY ART STUDIO)
(WITNESS)
(DATE)
(BODY ART STUDIO ADDRESS)
(DATE)