Fillable Printable Influenza Vaccine Consent Form
Fillable Printable Influenza Vaccine Consent Form
Influenza Vaccine Consent Form
INFLUENZA VACCINE
CONSENT FORM
This organisation proudly
vaccinates with Australian
made flu vaccine
I have read and understood this
information and the Consumer
Medicine Information for
influenza vaccine. I consent to
receiving a flu vaccine.
IMPORTANT
QUESTIONS
1
Do you have a
fever or are you
currently unwell?
2
Have you been
vaccinated against
influenza before?
3
Have you ever
experienced any
problems after
vaccination?
4
Are you
allergic to
chicken eggs?
5
Are you allergic
to Neomycin or
Polymyxin?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Name
Date of Birth
Organisation/Employer
Employee Number
Department
Signature
Date
FOR OFFICE USE ONLY
Flu vaccine given by
Batch number
Signature
Date
VACCINATION IS YOUR BEST DEFENCE
AS RECOMMENDED BY THE WORLD HEALTH ORGANISATION
THINGS YOU SHOULD KNOW
• Influenza vaccine can never give you
the flu. The vaccine does not contain
any live virus.
• The influenza vaccine is generally well
tolerated but you should stay close by
for 15 minutes - so we can keep an eye
on you for the first few minutes after
your vaccination.
• Like all medicines, this vaccine may
have some side-effects. These are
usually very mild and do not last for
long. If you feel anything that worries
you, call your doctor for advice.
• Some people report redness or discomfort
at the site of the injection, this should
disappear within a few days.
• A few people report mild fever and
muscle pains or feel generally unwell
for one or two days after the
vaccination. These flu-like symptoms
do not mean you have the flu. They are
most likely to be your body’s natural
response to the vaccine.
• If you are pregnant or breastfeeding
please discuss influenza vaccination
with your doctor or nurse.
If you have any questions
• Talk to your doctor or nurse.
bioCSL Pty Ltd. ABN 26 160 735 035. 63 Poplar Road, Parkville, VIC 3052, Australia. bioCSL™ is a trademark of CSL Ltd. Date of preparation: November 2012.
10457. DC5357.
You must be assessed individually and provide informed consent by signing this
form before vaccination. If you have any questions, you are advised to talk to your
doctor, pharmacist or other healthcare provider. Consumer Medicine Information
leaflets for influenza vaccines are available at your work place vaccination
site or upon request. These leaflets include the side-effect profile of influenza
vaccination and give information on people who should not receive the vaccine.
PLEASE ANSWER THE QUESTIONS OVERLEAF
BEFORE YOU GET YOUR INFLUENZA VACCINATION
The information provided will
not be given to anyone else. It
will be used only in connection
with the administration of
the influenza vaccine and will
otherwise be kept private
and confidential.
If you answer YES to any
of these questions please
make sure you talk about
this with the nurse or doctor
before vaccination.
NOTE: It’s important to
let us know if this is the
first time that you have
had an influenza
vaccination.
