RKMRS Vaccination Pre-screening/ Consent & Recording Form

VACCINATION PRE-SCREENING/ CONSENT & RECORDING FORM

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1. PERSONAL DETAILS (PERSON TO BE VACCINATED)
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medicare Number (must include subnumerate)*
Medicare expiry*
Date of Birth*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Gender

FemaleMalePrefer not to say

3. CONSENT TO RECEIVE IMMUNISATION
I have been given, and understand the information provided to me regarding the vaccine and possible side effects. If I have further questions, I will ask the immuniser before I am immunised. I consent to receiving the INFLUENZA 2024 vaccine.
I consent to a copy of my Statement of Immunisation being provided to my nominated medical practitioner.

YesNo
I understand:
- I must remain within the designated waiting area for a period of 15 minutes after vaccination for observation and so that I may receive additional medical attention, including emergency care, if needed.
- This service will be recorded on the Australian Immunisation Register.
- I have been advised of, and agree to pay the charges associated with this service.
Name

First NameLast Name
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

VACCINATION PRE-SCREENING/ CONSENT & RECORDING FORM