"" 1 Please complete the form below and I will contact you back as soon as possible to confirm your vacination. Name Address Phone Number Email Date of Birth Allergies0 / General Practitioner name and contact details0 / Are you of Aboriginal or Torres Straight Islander origin?Mandatory questionNoYes, AboriginalYes, Torres Strait Islander VACCINATION NEEDS ASSESSMENTDo you answer yes to any of the following, please tickDo you live with someone who is on immunity lowering treatment?Have you been in contact with someone who is ill?Are you pregnant or planning pregnancy?Do you live with someone who has a disease that lowers immunity?Do you have a functioning spleen?None of the above GENERAL HEALTH AND SUITABILITY FOR VACCINATIONHave you ever fainted after immunisation?Have you a chronic illness?Have you had a severe reaction to a vaccine?Are you unwell today with a temperature over 38.50 C?Have you had any severe allergies, including eggs?Have you had a vaccine in the last month?Are there any other reasons that a vaccine may affect you?Are you having treatment that lowers immunity?Have you a history of Guillain-Barré Syndrome?Have you had a disease that lowers immunity?Have you had immunoglobulin in the last year?Have you received any blood products in the last year?Are you pregnant or anticipating pregnancy?None of the above CONSENTI have read and understood the frequently asked questions and information provided regarding possible side effects of the vaccine. If I have any further questions I will ask the person administering the vaccine prior to being vaccinated. I request to have this vaccination and understand that it is completely voluntary. I agree to stay in the pharmacy for 15 minutes and that there may be possible adverse effects which have been explained by the pharmacist. I hereby give permission for the pharmacy to provide my personal record of my vaccination to my nominated general practitioner/medical centre.I Accept the Above Terms & Conditions Submit Form Previous Next
