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Home
About
About HomeCentris
Vision & Values
Leadership Team
Services
Home Care
Transitional Services
Skilled Home Health
Veterans Program
Primary Care Housecalls
Ancillary Services
News & Media
Home Care Resources
Careers
Join our Team
Existing Team
Contact
Home
About
About HomeCentris
Vision & Values
Leadership Team
Services
Home Care
Transitional Services
Skilled Home Health
Veterans Program
Primary Care Housecalls
Ancillary Services
News & Media
Home Care Resources
Careers
Join our Team
Existing Team
Contact
Form – Hep B Declination
Matt Auman
2019-04-02T09:05:26-04:00
Hepatitis B Vaccination Declination
Hepatitis B Vaccination Declination Form
Applicant Name:
*
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.
Date
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Email Address: We will email you a signed copy.
*
Signature
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If you are human, leave this field blank.
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