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Download Hepatitis B Vaccination and Post-Vaccination Serology Results
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Hepatitis B Vaccination and Post-Vaccination Serology Results Pediatric provider: Please complete this form each time the child named below receives a hepatitis B vaccination and post-vaccination serology and fax to the number below. Public Health Agency: _________________________________________ Case Coordinator: ____________________________________________ Phone Number: _________________ Fax Number: __________________ Child Name: ___________________________________________ Child DOB: ___________________________________________ Mother Name: _________________________________________ Mother DOB: __________________________________________ Hepatitis B Vaccination Vaccine Date (Circle) HBIG --------- (LPH complete) Heb B 1 (LPH complete) Engerix Recombivax Engerix Pediarix Hep B 2 Recombivax Engerix Pediarix Hep B 3 Recombivax Engerix Pediarix Hep B 4 Recombivax Post-Vaccination Serology Results Serology test Date (Circle) HBsAg Positive Negative Anti-HBs Positive Negative Form completed by: _____________________________________ Clinic name: ___________________________________________ Phone number: _________________________________________ Should you have questions, please feel free to contact me at the number above. Thank you for your assistance.
