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CITY OF ST. ANTHONY <br /> HEPATITIS B VACCINE CONSENT/REFUSAL FORM <br /> I have read the policy statement and the information sheet about Hepatitis B and the <br /> Hepatitis B vaccine. I have had a chance to ask questions. I have all the information I <br /> desire and understand the benefits, risks and possible adverse effects consenting to or <br /> refusing the Hepatitis vaccination. I accept those risks. I understand that if I consent to <br /> the vaccination I must have three separate vaccinations. I understand it is my <br /> responsibility to receive the doses according.to the schedule. I further understand that <br /> the vaccine has been offered to.me at no cost. <br /> I wish to receive the Hepatitis vaccinations. <br /> Signature Date <br /> I prefer not to receive the Hepatitis B vaccine and decline the opportunity <br /> to be vaccinated. I do understand that I may receive the vaccination series <br /> in the future at my request. <br /> Signature Date <br /> PLEASE RETURN TO THE CITY CLERK <br />