Influenza Flu Vaccine Consent Form printable pdf download

INFLUENZA FLU VACCINE

CONSENT FORM

IMPORTANT: Person giving consent should read the immunisation information provided, before completing this

section. Any queries regarding vaccination can be discussed with the Registered Nurse prior to immunisation.

PLEASE PRINT –

USING BLOCK LETTERS

Name:

_________________________________________________ Date of Birth: ____/____/____ Age: _____

Address:

___________________________________________________________________

Male / Female

Postcode: _____________ Phone Number: ____________________ Employer:

___________________________

Which Council area do you reside in: _______________________________________________________

Please read the following information and answer questions below;

• The

•

Influenza

vaccine

generally

well

Influenza vaccine cannot give you the flu. The vaccine does

tolerated. After vaccination we request that you

not contain any live virus.

wait 15 minutes, the Registered Nurse is readily

•

The influenza vaccine is very safe. Most people experience

available if there are any immediate concerns.

minimal symptoms after their vaccination. However some

The recommendation is not to drive or operate

people may experience redness or soreness at the injection

machinery

for

minutes

following

site. Mild flu like symptoms can occur and resolve within a

vaccinations.

few days. These include mild fever, headache, muscle pain.

• Post vaccination you will receive a Vaccine

This is most likely to be your body’s immune response to the

Influenza Vaccine

Safety Information/Record Sheet. If you have

any concerns refer to this advice sheet and

phone numbers provided.

It is important to answer the following questions for assessment on your medical health in order to receive the

influenza vaccine.

IMPORTANT QUESTIONS – PLEASE CIRCLE

YES

1. Do you have a fever or are you currently feeling unwell?

YES

2. When was your last influenza vaccine? Year: .....................................................................

YES

3. Have you experienced any problems after vaccination? Please describe;

YES

...............................................................................................................................................

4. Do you have any allergies? Eg; chicken eggs or any medication

YES

...............................................................................................................................................

5. Are you allergic to the following antibiotics; Neomycin, Polymyxin or Gentamicin?

YES

6. Do you suffer from any medical conditions? Please describe;

YES

...............................................................................................................................................

7. Are you taking the following medications? Warfarin Theophylline, Penytoin, Penobatbitone,

Cabamazepine?

YES

8. Do you identify as Aboriginal or Torres Strait Islander?

YES

9. Women only: Are you pregnant?

YES

NOTE: If you have any questions about this information or any other matter relating to vaccination, please ask

your GP or Registered Nurse before the vaccine is given.

I have read and understood this information and the information provided for Influenza vaccine.

I consent to receiving a flu vaccination.

Signature: ............................................................................................. Date: ............................................

FOR OFFICE USE ONLY

Flu vaccine given by

Batch number

Signature ………………………… Site: LA / RA

Date ……………….. Time ..................

D15/10381

Influenza Flu Vaccine Consent Form

Related Articles

Related forms

Related Categories