Web Dental Professionals Hepatitis B Virus Vaccination Form printable pdf download

Web Dental Professionals Hepatitis B Virus Vaccination Form

Hepatitis B Virus Certification

(Dentists, Dental Hygienists, Dental Assistants)

___________________________________________________________________

PRINT NAME

___________________

DATE

I understand that due to my occupational exposure to blood or other potentially infectious

materials (OPIM), I may be at risk of acquiring hepatitis B virus (HBV) infection.

SIGN ONE OF THE FOUR STATEMENTS BELOW

1. I,

, have received the Hepatitis B

(SIGN)

vaccination

series on __________________at_______________________________________.

2. I,

, have had a Hepatitis B titer

(SIGN)

performed

on __________________at_______________________________________.

3. I,

, have not received the Hepatitis

(SIGN)

B vaccination series, but would be interested in doing so. I can receive the vaccination

series at a local health department, my private physician’s office or at no charge through

my employer.

4. I,

, decline the Hepatitis B

(SIGN)

vaccinations 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 a local health

department, my private physician’s office or at no charge through my employer.

Web Dental Professionals Hepatitis B Virus Vaccination Form