Consumer 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 sub-number.
Medicare Expiry*
Date of Birth*

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

FemaleMalePrefer not to say

3. CONSENT TO RECEIVE IMMUNISATION
You will been given information regarding the vaccine and possible side effects. If you have further questions, please ask the immuniser before being immunised.

I consent to receiving the Influenza vaccine.
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.
Name

First NameLast Name
Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

VACCINATION PRE-SCREENING/ CONSENT & RECORDING FORM