Pre-FIu Immunisation Screening and Consent

Pre-FIu Immunisation Screening and Consent

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
Name

First NameLast Name
Address

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Email
example@example.com
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*

YesNo
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)*

YesNo
You have severe allergies (to anything)*

YesNo
Please list allergies
You have had a severe reaction following any vaccine*

YesNo
Have you received any other vaccination in the last 7 days?*

YesNo
You have had an injection of immunoglobulin, or have received any blood products or a whole blood transfusion within the past year*

YesNo
You are pregnant*

YesNo
You are planning pregnancy or anticipating parenthood*

YesNo
You have a history of Guillain - Barre syndrome*

YesNo
You were a pre-term infant*

YesNo
You have a chronic illness*

YesNo
You have a bleeding disorder*

YesNo
You are of Aboriginal or Torres Strait Islander descent*

YesNo
You do not have a functioning spleen*

YesNo
You are a parent, grandparent or a carer Of a newborn*

YesNo
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)*

YesNo
You are planning travel*

YesNo
You have an occupation or lifestyle factor(s) for which vaccination may be needed (discuss with doctor/pharmacist/nurse).*

YesNo
Please Specify: Type a label
Pharmacist Notes
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
Please confirm your mobile number:
Please enter a valid phone number.
Name of patient (or parent/guardian of child): *
Signature of patient (or parent/guardian of child): Signature*
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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Pre-FIu Immunisation Screening and Consent

Pre-FIu ImmunisationScreening and Consent

Consumer Details

Primary Healthcare Provider

General Health and Suitability for Vaccination

Consent

Pre-FIu Immunisation
Screening and Consent