Hepatitis B Vaccine Declination Form

Document a decision to turn down the hepatitis B vaccine and keep the record on file. It captures identification and contact details, whether the person was immunised before, the reason behind the refusal, and a signed acknowledgement of the risks involved. Clinics, occupational health teams and employers can archive every response.

Use this template

In the Claude connectors directory

Full Name

First Name

Last Name

Date of Birth

Address

Street Address

City

State / Province

ZIP / Postal Code

Phone Number

Email

Have you received the Hepatitis B vaccination in the past?

Yes No Not sure

Reason for declining the Hepatitis B vaccination

I acknowledge that by declining the Hepatitis B vaccination, I may be at risk of contracting Hepatitis B.

I understand the risk of exposure I know I may request the vaccine later

Signature

Sign here

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