Fill out the form below OR Download Hepatitis B Immunization Acceptance or Declination PDF Form Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastDO YOU CURRENTLY HAVE ANY OF THE FOLLOWING THAT HAS LASTED THREE (3) WEEKS OR LONGER? LayoutUnexplained productive cough? *YesNoUnexplained appetite loss? *YesNoNight sweats? *YesNoChest pain? *YesNoBloody sputum? *YesNoUnexplained weight loss? *YesNoUnexplained fever? *YesNoShortness of breath? *YesNoIncreased fatigue? *YesNoHAVE YOU EVER? LayoutEver been told you have TB? *YesNoHad a positive TB skin test? *YesNoLived with anyone with TB? *YesNoHad a BCG vaccination? *YesNoPlease acknowledge and Initial *I acknowledge and certify that all answers provided on this form are true and accurate to the best of my knowledge.LayoutInitial Here *Date *Submit Form