106 West Main St, 2nd fl,
Johnstown NY 12095
t:518-762-1767 
f:518-762-1768

607 Marcy Avenue,
Brooklyn NY 11206
t: 914-219-0775
f: 718-889-7145

1 Hillcrest Center Suite 214,
Spring Valley NY 10977
t:
845-250-1800 
f: 718-889-7145


HEPATITIS INFORMATION ACKNOWLEDGEMENT

ACCEPT OR DECLINATION STATEMENT
 

Hepatitis B infection is a viral  Hepatitis B infection is a viral infection of the liver which may be transmitted from person to person by direct contact with blood/body fluids, secretions, or excretions of the infected person. This can be transmitted from individuals who are carriers of the disease to facility personnel. A carrier of Hepatitis B is defined as a person who may or may not have symptoms of the infection, and in whom the virus remains alive in the blood or other body fluids. Hepatitis B infections may result in chronic infection of the liver, cirrhosis, and less frequently, liver cancer

Consent
If I accept the vaccination, I understand that I will be given the opportunity to participate in the series, which includes injections at 0, 30, and 180 day intervals. I will comply with the administration procedure, and am aware of the adverse effects, contraindications, and complications that may occur due to the Hepatitis B Vaccination.

Declination
If I decline the vaccination, I either have received the vaccination prior, OR 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 have been given opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, 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 at no charge to me.

 
I DECLINE the Hepatitis B Vaccine inoculation

I Accept the Hepatitis B Vaccine inoculation
 
I have read and understand the information regarding Hepatitis B. My signature below indicates acknowledgment of this information and my decision to either accept or decline the Hepatitis B vaccination.
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