Hepatitis B Workplace Immunization Consent Form
Personal Information
Full Name
Date of Birth
Employee ID
Department
Medical Screening
Do you have any allergies? If yes, please specify.
Have you previously received the Hepatitis B vaccine?
Yes
No
Unsure
Current medical conditions (if any)
List any current medications
Consent
I have received and read information about the Hepatitis B vaccine.
I understand the benefits and possible side effects of the vaccine.
I give my consent to receive the Hepatitis B vaccination.
Signature
Date
For Office Use Only
Dose 1 Date
Dose 2 Date
Dose 3 Date
Administered By
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