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Ained to me, and understand the information in the clinic notice and the hepatitis B fact sheet. -I have been able to ask questions and had my questions answered. -I know that if I do not cancel my consent, this form will be used for 2 doses. -I know that my consent is voluntary and I can call the Durham Region Health Department to cancel my consent. YES, I consent to having the hepatitis B vaccine. NO, I do not consent to having the hepatitis B vaccine. Student Signature.

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