PLACE LABEL HERE
PLACE LABEL HERE
SummitRidge
Form Name
I have read or have had explained to me the information in the Centers for Disease Control and Prevention Vaccine InformationStatement (VIS)for Hepatitis Bprovided by Gwinnett Hospital System. I have had a chance to ask questions, which were answered to my satisfaction and I understand the risks and benefits of the Hepatitis B Vaccine. I understand that my baby's doctor recommends that my baby receive this vaccine soon after birth and that this vaccine is also recommended by the AmericanAcademy of Pediatrics.
YES I request that my newborn infant receive Hepatitis B Vaccine.
Date: ______Time: ______Signed: ______
Parent or Authorized Representative
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NO IDO NOT want my newborn infant to receive Hepatitis B Vaccine.
Date: ______Time: ______Signed: ______
Parent or Authorized Representative
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FOR HOSPITAL USE ONLY
See HHS Immunizations for details
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Date/Time givenSiteLot numberManufacturer
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RN/LPN Signature
Gwinnett Hospital System complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Gwinnett Hospital System does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
FORM 2-18777 REV. 04/2013 Page 1 of 2
PLACE LABEL HERE
HEPATITIS B VACCINE
REQUEST
Yo he leído o se me ha explicado la información en la Declaraciónde Información Sobre Vacunas por la vacuna contra la hepatitis Bde los Centros para el Control y la Prevención de Enfermedades (CDC) provista por el Gwinnett Hospital System.Yo he tenido la oportunidad de hacer preguntas, las cuales fueron contestadas satisfactoriamente, y yo entiendo los riesgos y beneficios de la vacuna contra la hepatitis B. Yo entiendo que el médico de mi bebé recomienda que mi bebé reciba la vacuna después del nacimiento y que esta vacuna también es recomendada por la American Academy of Pediatrics (Academia Americana de Pediatras).
SI yo solicito la vacuna contra la hepatitis B para mi recién nacido.
Fecha: ______Hora: ______Firmado por: ______
Padre o Representante Autorizado
______
______
NO, YO NO quiero que mi recién nacido reciba la vacuna contra la hepatitis B.
Fecha: ______Hora: ______Firmado por: ______
Padre o Representante Autorizado
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PARA USO HOSPITALARIO SOLAMENTEFor hospital use only
See HHS Immunizations for details
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Date/Time given Site Lot number Manufacturer
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RN/LPN Signature
Gwinnett Hospital System cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Gwinnett Hospital System no excluye a las personas ni las trata de otro modo por motivo de su raza, color, origen nacional, discapacidad o sexo.
FORM 2-18777 REV. 12/2016 Page 1 of 2