Influenza Consent Form

Full Name*

TitleFirst NameLast Name

Date of Birth*

DayMonthYear

If child name of Guardian / Parent

First NameLast Name

Have you attended this clinic previously*

YesNo

Are you well today?*

YesNo

Have you had the flu injection previously?*

YesNo

Any allergic reaction to the Flu or any other immunisation?*

YesNo

Any allergy to eggs or egg protein?*

YesNo

Eligibility for the government funded flu immunisation:*

Risks and Possible Side Effects of Vaccine:

Adverse reactions to vaccinations are generally mild.
After vaccination, 2% to 5% of patients may have mild headaches, myalgia, low grade fever, or other minor symptoms for 5 to 10 days.
Immediate hypersensitivity reactions, characterized by rash, urticaria, and/or asthma are uncommon and occur primarily among persons with history of egg allergy.

Consent:

This is to confirm that I have read and understand the above information and other printed vaccine information provided
My responses are accurate to the best of my knowledge.
I have understand that any questions I may have about the vaccine, can be discussed with the Doctor or Nurse.
It is recommended that I wait in the clinic for at least 15 minutes after any vaccination, and i should return immediately to the clinic or the nearest hospital, if I have any changes, including a rash, pain, difficulty breathing or any other symptoms.
I confirm that having the vaccine is my choice and I hereby consent to receiving the immunisation listed below

Thank you for completing this online consent form online. With the Covid-19 outbreak we are attempting to reduce physical contact of consent forms.

By signing and submitting this form, I understand the above risks and possible side effects and agree to receive the Influenza vaccine

Please see our Clinic privacy policy

Signature:*

Date*

DayMonthYearHourMinutes