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. The risk and Benefits have been explained to me and I have been given the opportunity to be vaccinated with hepatitis B vaccine. However, I decline hepatitis vaccination at this time. I understand that by declining the vaccine, I continue to be at risk of acquiring hepatitis B, a serious and often fatal disease. If in the future I acquire hepatitis B,I will not hold The Fullerton Dental Assistant School or Eric Meyer D.D.S responsible for my decision to not be vaccinated with the hepatitis B vaccine.
