Hepatitis B Statement (Student) .pdf

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Original filename: Hepatitis B Statement (Student).pdf
Title: Hepatitis B Statement

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Hepatitis B Student Statement
Please sign and email return to jared@3dBrowsAcademy.com

I 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 read and
understand the health risks involved with Hepatitis B. I fully
understand the risk of its transmission, and have full
knowledge of its effects on the human body.
Check the box that best represents you!

I voluntarily 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.
I have received a current Hepatitis B vaccination and I will
provide a copy of my Hep. B vaccination.
I have received a current Hepatitis B vaccination and I have
lost or I am waiting on a copy of my vaccination history from my
medical provider.

Signature:

Date:

Printed Name:

Address:
City, State:

3D Brows Academy 949 e. Pioneer Rd. #B2 Draper, UT 84020


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