I, , have been requested by Horizons Healthcare Agency to obtain vaccination against Hepatitis B and to have the first vaccination administered before I begin employment.

I understand that this vaccination is designed to protect staff members that care for clients who are Hepatitis B positive. Even though Horizons Healthcare Agency has explained this to me and requested that I receive the Hepatitis B vaccination before starting employment with them, I have chosen not to receive this vaccination for:

MedicalPersonal

I agree to hold Horizons Healthcare Agency harmless should I contract Hepatitis B through my employment with Horizons Healthcare Agency.