Laserfiche WebLink
Consent Form <br /> I have read the above information <br /> B vaccine (�OMBIVAX H.B about hepatitis B and the synthetic hepatitis <br /> ) . I have had an <br /> ,opportunity to ask questions and <br /> understand the benefits and risks of hepatitis B vaccination. <br /> I understand that I must have three doses of vaccine to confer <br /> However, there is no guarantee that I will becomet I will <br /> i l <br /> experience any adverse side effects from the vaccine. I request that itbegiven to me. <br /> nim �clD /e //�&?/�F. <br /> •��« �l pErson to receive vaccine <br /> (print) <br /> Lo <br /> 41n,t-ure" of �` )�1 0 <br /> 7 <br /> person rece.ivi.ng vaccine <br /> �v� <br /> itness�AL ate <br /> Date Vaccinated Lot No. <br /> Signature <br /> 0 <br /> o� <br /> ,Cti <br /> 3) <br /> CS:er-8/15 <br />