University Hospital of Brooklyn
OWNSTATE Collage of Medicine
Medical Center School of Graduate Studies
College of Nursing
College of Health Related Professions
StudentiEmployee Health Service
HEPATITIS B CONSENT
have read and understand the
(Print Nama)
‘Statement about Hepatitis 8 vaccine. {have had an opportunity to ask questions and understand the
benefits and risks of Hepatitis B vaccination. | understand that | must have three (3) doses of vaccine
to confer immunity. However, as with all medical treatment, there is no guarantee that | will become
immune or that | will not experience’an adverse side effect from the vaccine. I request that it be given
tome.
(Signature of Partonrecelving Vaccine) eoxr (Cate signed)
DATE DUE DATEVACCINATED. LOT #EXP DATE ADMINISTERED BY
Dose
Dose #2
Dose #3 .
Booster
DECLINATION
TO HEPATITIS B VACCINE
understand that due to my occupational exposure to blood
‘Praneme)
or other potentially Infectious materials | may be at risk of acquiring Hepatitis B Virus (HBV) infection.
‘have been given the opportunity to receive hepatitis B vaccine, at no charge to myself. However, |
decline Hepatitis B vaccination at this time. | understand that by declining this vaccine, | continue to
bbe at risk of acquiring Hepatitis B, a serious disease. ifin the future | continue to have occupational
‘exposure to blood or other potentially infectious materials and | want to be vaccinated with Hepatitis
B vaccine, | can receive the vaccination series at no charge to me therefore | am declining it at this
time.
(Signature of Person decning Vaccine)
or
fl claim to have previously received
eomivams)
Hepatitis B Vaccine from
(Print Name PerneniFactity/Oate Vaccine Received)
State University of New York Downstate Medical Center
450 Clarkson Avenue, Box 33, Brookiyn, NY 11203-2098 » Phone 718 270-1995 / 1969 Fax718 270-2477