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
Page 1/2
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Influenza Vaccine Consent Form PDF

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