Antenatal Vaccination Consent Form
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WA Health – Public Health
Hospital/Health Service Name
MRN/UMRN Label
Communicable Disease Control
(use stamp or write in)
Directorate
Antenatal Vaccination Authorisation and Consent Form
E X A M P L E
1 2 3
Please Print Neatly in Capital Letters
Last Name
Postcode
First Name
/
/
Telephone Number
Date of Birth
(MOBILE Preferred)
(eg., 25/08/1980)
Yes
No
Do you identify yourself as Aboriginal or Torres Strait Islander?
This consent form is designed for use with pregnant women consenting to influenza and/or pertussis vaccination at antenatal clinics and
community/public health immunisation centres.
Consent for influenza and/or pertussis vaccine during pregnancy
By shading the appropriate circles and signing below:
►
I have read and understand the information given to me about influenza and/or pertussis vaccination in
Yes
No
pregnancy regarding the anticipated benefits and possible side effects of vaccination.
►
I have had an opportunity to have my questions answered.
Yes
No
►
I acknowledge that, as a precaution, after the vaccination I will be requested to wait for 15 minutes before
Yes
No
leaving the clinic area.
Consent to being contacted by WA Department of Health for quality assurance
As part of our ongoing efforts to continuously monitor vaccine safety, WA Health is requesting your permission to contact you
by SMS or telephone to ask about your vaccination experience. If you agree, you will receive an SMS or telephone call
several days after vaccination from a Department of Health representative asking whether you experienced any side-effects,
including minor ones, following vaccination. You will not be contacted for any other purpose and your information will be kept
confidential.
►
I acknowledge that by agreeing my healthcare provider will
send this form to the Department of
Health at
Yes
No
the time of my vaccination
►
I give my permission to be contacted by telephone or SMS by the WA Department of Health and asked
Yes
No
about my vaccination experience in order to monitor vaccine safety.
►
I am aware that my decision to participate in this follow-up program is voluntary and will in no way impact
Yes
No
the care that I receive.
d
d
m
m
y
y
y
y
Signature of person receiving vaccine(s)
Date:
/
/
To be completed by person administering vaccine
►
Has the person being vaccinated ever had anaphylaxis following previous doses of either of these vaccines?
Yes
No
►
Has the person being vaccinated ever had anaphylaxis following any component of either of these vaccines?
Yes
No
A “Yes” response warrants further discussion and consideration prior to administration of the vaccine. If you have questions please consult the
patient’s primary care physician or relevant specialist. Note that most egg allergic patients can safely receive influenza vaccine, but individuals with a
history of anaphylaxis to eating eggs should consult with an allergy specialist prior to being vaccinated
d
d
m
m
y
y
y
y
/
/
/
Week of pregnancy when vaccinated:
weeks
Estimated date of delivery:
OR
Vaccine(s) administered today:
(recommended for women in all trimesters who are pregnant during influenza
INFLUENZA VACCINE
season):
Vaxigrip
Fluarix
Fluvax
Other____________________
Vaccine Brand
Or write batch number here:
Batch number sticker
here
rd
(recommended for women in 3
PERTUSSIS VACCINE
trimester of each
pregnancy):
Adacel
Boostrix
Other____________________
Vaccine Brand
Or write batch number here:
Batch number sticker
here
Vaccine ordering account number:
Name and designation of person administering vaccine(s) PLEASE PRINT
d
d
m m
y
y
y
y
Date:
Signature of person administering vaccine(s)
PLEASE SCAN
and
EMAIL
the completed form to CDCD at
antenatal.immunisation@health.wa.gov.au
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