Please circle your choices (bolded below), then sign your name and write the date.

I .............................................................
(full name)

give my consent to register with the National Hepatitis Follow-up Programme run by the Hepatitis Foundation.

I understand that no information about my condition will be released to anyone except for those health workers involved in carrying out this programme, or officers of the Ministry of Health who are responsible for monitoring the programme, without my written consent.

I give / do not give my consent that my blood results are passed on to my family doctor and previous results (with regard to hepatitis B or C) be obtained from my family doctor.

Doctors Name: ......................................

Doctors Address: ...................................

.............................................................

.............................................................

I give / do not give my consent to the
Hepatitis Foundation contacting people that I name for a blood test to check their hepatitis status.  Such people could be:-

• a whanau / family relationship e.g.
  parent, blood sibling, or offspring of the carrier


• a sexual relationship
  
• a close household relationship
  

Signature: .............................................

Date: ..................................................

FOLLOW- UP OF HEPATITIS CARRIERS

The Hepatitis Foundation has set up a National Programme of follow-up of hepatitis B and C carriers.  We have a confidential register of carriers who are provided with simple regular blood tests (usually every six months) to make sure their livers are healthy.  You will be included in this register if you wish.

Any liver problems can usually be detected early.  If liver problems are found, you will be told, and there may be a suitable treatment.  We will refer you to a liver specialist to get this.

If any further information is required on our carrier surveillance programme please contact us on
0800 33 20 10
or email hepteam@hepfoundation.org.nz.

You may like to visit our web-page at:
www.hepfoundation.org.nz.

The Hepatitis Foundation
PO Box 647
61A Alexander Avenue
Whakatane
New Zealand

Phone 64 07 307 1259
Fax 64 07 307 1266
Freephone in New Zealand:
0800 33 20 10

hepteam@hepfoundation.org.nz

Freepost No 191379,
The Hepatitis Foundation,
PO Box 647,
Whakatane.

Free-phone: 0800 33 20 10