Hepatitis-A Vaccine Form

Welcome to our Hepatitis-A Vaccine Form

Please fill out this form so your clinician can recommend the best treatment plan for you.

First Name

Last Name

Phone/Mobile

Address

Address Line 1

City

Postcode

Country

Date of birth

Sex at birth

Male

Female

Emergency Contact Name

Emergency Contact Phone Number

Select Appointment Date & Time

Vaccine Information and Consent

Please read the following information carefully:

The Hepatitis-A vaccine is recommended to protect against hepatitis-A, a highly contagious liver infection caused by the hepatitis A virus. The vaccine is usually given as a series of two injections, six months apart.

Common side effects: Pain at the injection site, headache, fatigue, and mild fever.
Serious side effects: Severe allergic reactions are rare but can occur.

I have read the information about the Hepatitis-A vaccine. I understand the benefits and risks of the Hepatitis-A vaccine and request that the vaccine be given to me or to the person named above for whom I am authorised to make this request.

Hepatitis-A Vaccine Form

Welcome to our Hepatitis-A Vaccine Form

Vaccine Information and Consent

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