Hepatitis B Vaccine Consent Form
Provides protection against Hepatitis B

Client Consent Details(person being immunised)
First Name / Surname
Date of Birth / Gender(Please circle) / Male / Female
Medicare Card Number / ______ref ___
Address
Suburb / Postcode
Telephone
Declaration / (Please circle)
I haveread and understood the information provided and give permission for / myself / my child
to be immunised against Hepatitis B.
Signature
(if under age of 18, parent/guardian signature required) / ______/ Date / ____ / ____ / ______
Please see the reverse side of this form for further information
IMMUNISATION USE ONLY
*Dosage / 2 or 3 doses depending on age of client. Please see reverse side of this form for direction
Cost / $ 21.00 per dose
Client Eligibility**(Please circle) Please see reverse of this form for criteria / Free / Paid
Cardholders Name
Card Type(Please circle) / Eftpos / Visa / MasterCard
Receipt Number / Date / Amount Paid / $
/ COUNCIL OFFICE USE ONLY /
ABN 98 606 522 719 / RC - VACHBA / Receipt Number / Amount / $
/ FOR CLIENT /
Client Name:
Today you receiveda dose of the Hepatitis Bvaccine from Maroondah City Council Immunisation Service.
Please retain this receipt for your records.
Date Given:
Important: Post vaccination, it is recommended that you remain at the immunisation venue for 15 minutes and do not drive for 30 minutes. / Office Use ONLY
Vaccine Brand
(Please circle) / Free / Paid

*Hepatitis B Dosages
IMPORTANT: Please refer to Pages 50, 51, 63 & 213 of ‘The Australian Immunisation Handbook, 10th Edition, 2013’ for clarification ANDconsult with the nursing staff. Please note: the birth dose is not included in the NIP.
Age / Dosage / Cost per Single Dose / Cost per Course
Aged 6w-19 years
(Paediatric formulation) /
  • 1st dose
  • 2nd dose one month LATER
  • 3rd dose two months AFTER the second vaccination
/ Free for all children under the age of 19 / --
Aged 11-15 years only
(Adult formulation) /
  • 1st dose
  • 2nd dose four months LATER
/ Free for all children under the age of 19 / --
20 years or older
(Adult formulation) /
  • 1st dose
  • 2nd dose one month LATER
  • 3rd dose five months AFTER the second vaccination
/ $20.00 / $60.00
**Information: Eligibility for FREE Vaccines in Victoria
Vaccine / Criteria
Hepatitis B
(both adult and paediatric formulations) /
  • Household contacts or sexual partners of people living with hepatitis B infection
  • People who inject drugs or are on opioid substitution therapy
  • People living with hepatitis C
  • Men who have sex with men
  • People living with HIV
  • Prisoners and remandees
  • People no longer in a custodial setting who started, but did not complete the vaccine course while in custody

Last Updated June 2017

Maroondah City Council_ DTP Consent Form_ July 2016
Last Updated: June 2017QMS ID:Review Date: June 2018