• Pre-FIu Immunisation Screening and Consent

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    Wamberal Pharmacy

    658 The Entrance Road
    WAMBERAL
    NSW 2260
    Phone: 02 4384 1994
    Email:wamberalpharmacy@hotmail.com

    Pre-FIu Immunisation
    Screening and Consent

  • Consumer Details

  • Primary Healthcare Provider

  • Format: 0000000000.

  • General Health and Suitability for Vaccination

  • Please tell your nurse, doctor or pharmacist if you answer yes to any of the following statements as vaccination may not be suitable for you today.

  • You are unwell today*
  • You have a disease that lowers immunity (e.g. leukemia, cancer, HIV/AIDS) or having treatment that lowers immunity (e.g. oral steroid medicines such as cortisone or prednisolone, radiotherapyor chemotherapy)*
  • You have severe allergies (to anything)*
  • You have had a severe reaction following any vaccine*
  • Have you received any other vaccination in the last 7 days?*
  • You have had an injection of immunoglobulin, or have received any blood products or a whole blood transfusion within the past year*
  • You are pregnant*
  • You are planning pregnancy or anticipating parenthood*
  • You have a history of Guillain - Barre syndrome*
  • You were a pre-term infant*
  • You have a chronic illness*
  • You have a bleeding disorder*
  • You are of Aboriginal or Torres Strait Islander descent*
  • You do not have a functioning spleen*
  • You are a parent, grandparent or a carer Of a newborn*
  • You live With someone Who has a disease that lowers immunity (e.g. leukemia, cancer, HIV/AIDS) or live with someone who is having treatment that lowers immunity (e.g. oral steroid medicines such as cortisone or prednisolone, radiotherapy or chemotherapy)*
  • You are planning travel*
  • You have an occupation or lifestyle factor(s) for which vaccination may be needed (discuss with doctor/pharmacist/nurse).*

  • Please Specify:      

  • Consent

  • • I have been provided with, read and understood information regarding the possible side effects of each vaccine, and if I have further questions, I will ask the immuniser prior to being vaccinated.

    • I understand that if my health insurer or employer is paying for this service, your name may be disclosed for the purposes of verification, payment and invoicing. Personal health information provided in the pre-screening form or discussed with your pharmacist will not be disclosed to any party.

    • I understand and agree to stay in the pharmacy for a 15 minute period post the vaccination.

    • I request to have each vaccine and understand that it is completely voluntary.

    • I have been informed of, and agree to pay the fees

  • Format: 0000000000.

  • Name of patient (or parent/guardian of child):     *   

  • Signature of patient (or parent/guardian of child):     *      

  • Date:          Pick a Date   

  • The Pre-Flu Immunisation Screening and Consent form ("The Document") has been developed in electronic format by MedAdvisor International Pty Ltd ("MedAdvisor") based on the Practice guidelines for the provision of immunisation services within pharmacy (Dec 2014) developed by the Pharmaceutical Society Of Australia (the guidelines) and the Australian Immunisation Handbook (June 2015) developed by the Australian government, Department Of Health (the guidelines). The Document must used in accordance with the guidelines and other relevant industry standards, cxxies, regulations and laws, Consistent with the guidelines pharmacists must exercise professional judgement in using the Document, this may include adapting it to better address specific presenting circumstancns, MedAdvisor accepts no liability for any loss with any person that may suffer as a result of reliance on the Document or any information contained therein.

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