Consent Form for Hepatitis B Immunization
Student First Name:________________________ Student Last Name:____________________________
Male  OR  Female        Birth Year:__________ Birth Month:______________ Day of Month:___________
Street Address:________________________________________________________________________
City:________________________ Postal Code:___________________
Home Phone Number:______________________ Cell Phone Number:__________________________
Health Card Number (Optional):__________________________________
Teacher:________________________ School:_______________________________________________
If your child has already been immunized for Hepatitis B, including Twinrix, write the names and dates below: _____________________________________________________________________________________
Note: hepatitis B is not to be confused with Hib (Haemophilus Influenza b)
Does your child understand what the hepatitis B vaccine is for?  Yes  OR  No
Is your child allergic to aluminum?  Yes  OR  No
Is your child allergic to yeast?  Yes  OR  No
Is your child allergic to formaldehyde?  Yes  OR  No 
Is your child allergic to latex?  Yes  OR  No
If your child has any other allergies please list them: _____________________________________________________________________________________
Does your child have any serious health issues? For example, bleeding disorders.  If yes, please list_______________________________________________________________
Is your child on any medications that may lower their immune system? For example a high dose of prednisone. If yes, please explain__________________________________________________________
Has your child ever had a reaction to any shots in the past? If yes, what type of reaction?_____________________________________________________________________________
Consent for immunization:
Yes, I want the Health Unit to give the complete hepatitis B vaccine series to my child.  Unless cancelled, this request is valid until the vaccine series is complete.
I have read or had explained to me the information about the vaccine. Any questions I had have been answered to my satisfaction. My child has not had a serious allergie to a vaccine, latex, aluminum, yeast, or formaldehyde.
Parent or Guardian Signature:_______________________________________________
Date form signed:___________________________________________
 OR you can choose to decline Immunization in this next section
No, I don’t want the Health Unit to give the hepatitis B vaccine to my child. I have read the information attached to this consent form. I understand the possible consequences if my child is not vaccinated with the vaccine.
Parent or Guardian Signature:_______________________________________________
Date form signed:___________________________________________