Last name

First name

M F

Address

City

Postal Code

Home phone

Work phone

Emergency

Date of Birth

(Write Name of Month )

Day / month/year

Manitoba Health # (6digit)

9 digit PHIN#

If not covered by Manitoba Health then provide other Health Care Numbers

Allergies

Prior reactions to Immunizations?

Egg Allergies?

Current Medications

Have you missed any childhood vaccinations?

Women: Could you be pregnant?

Date of last period:

e-MAIL:

Medical Problems

I have read the Employees Hepatitis A information Sheet Yes No

I consent to have Hepatitis A immunization understanding that this is elective and not compulsory Yes No

All medical information volunteered is confidential with our clinic

Your restaurant will only record that you have received the Hepatitis A on this date for purpose of billing

If you have any questions or concerns you may contact our office at any time before or after the immunization date

Hepatitis A 1#___________________________Date

Hepatitis A 2#_________________________Date