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Form – Hep B Declination
Matt Auman
2021-03-15T09:15:43-04:00
Hepatitis B Vaccination Declination
Hepatitis B Vaccination Declination Form
Applicant Name:
*
In which state do you work?
*
Maryland
Virginia
Pennsylvania
Certification
*
I, undersigned, hereby certify that I had been informed of the HomeCentris Healthcare, LLC and subsidiaries policies and procedures concerning Transmittable Diseases and received information concerning the Hepatitis B vaccination series. I have been given an option to receive Hepatitis B vaccination and, after careful consideration, decline this option. I indemnify HomeCentris and/or its subsidiaries of any responsibility in case of my contraction of this disease while employed or under contract with the HomeCentris and/or its subsidiaries.
Date
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Email Address: We will email you a signed copy.
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Signature
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