This questionnaire forms the basis of your online consultation. Please be honest and if you are unsure about any of your answers, please verify the information with your GP before using the service:

I am 18 years old or above.
I am using this service on my own behalf and of my own free will. Any treatment or advice is for my sole use only.

I confirm the above statements are true

Have you ever been diagnosed with hepatitis B infection?

Yes

No

Have you ever completed a vaccination course of three injections against hepatitis B?

No

Yes

Unsure

Have you ever received any vaccines against hepatitis B?

No

Yes

Unsure

How many vaccinations against hepatitis B did you receive?

When did you receive the injection(s)?

Within the last four years

More than four years ago

Not sure

Have you had a blood test to confirm your immunity to hepatitis B?

When was the blood test done?

Informed consent

I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the doctor can safely assess and advise me.
I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact Lloyds Online Doctor before proceeding.
I understand the side effects, effectiveness and alternatives to the treatment I am requesting.
I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.
I have read, understand and agree to the latest terms and conditions and privacy policy.

I confirm the above statements are true

Vaccination History

Informed consent

% of questionnaire complete

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