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-- -------- <br />neoatilis sm Vaccine Declination Form <br />Facility Name* <br />Facility Address: S + <br />I have been g'pjen the ♦e►♦ to ♦ vaccinated with the hepatitis B vaccine, <br />at no charge to myself. <br />vaccine, I can receive the vaccination serios�-at no •' to me. <br />Employee's Name (Print) <br />Employee's Signature <br />-t- <br />Date- <br />