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Form – Hep B Declination
Matt Auman
2019-04-02T09:05:26-04:00
Hepatitis B Vaccination Declination
Hepatitis B Vaccination Declination Form
If you are human, leave this field blank.
Applicant Name:
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Certification
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I, undersigned, hereby certify that I had been informed of the HomeCentris Healthcare, LLC and subsidiaries (Personal Home Care, HomeCentris Home Health, HomeCentris Community Care) 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.
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Email Address: We will email you a signed copy.
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