Vaccine*—Please choose an option—Influenza/Flu VaccineDTPA-Whooping coughMeasles, Mumps and Rubella (MMR)Influenza and DTPA Whooping cough
Full Name*
Address*
Postcode*
Contact Phone Number
Date of Birth (DD/MM/YYYY)*
Gender—Please choose an option—MaleFemalePrefer not to say
Email
Select Your Store—Please choose an option—BomaderryBox HillBurwoodCameron parkColebeeEastern creekNorth KellyvilleShell CoveSilkstoneSpringfarmVincentia
Do you have a high fever or are you currently unwell?*
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Do you have a disease that lowers immunity (e.g. cancer, HIV/AIDS) or are currently having treatment that lowers immunity(radiotherapy, chemotherapy)?*
Have you had anaphylaxis to another vaccine or medication?*
Have you ever fainted after a vaccination or are you especially scared of needles?*
Have you had any severe allergies (to anything) in the past?*
Have you received a flu vaccine in the last month?*
Have you had an injection of immunoglobulin, or received any blood products or a whole-blood transfusion within the past year?*
Are you planning a pregnancy, currently pregnant or breast feeding?*
I am legally authorised to provide consent on behalf of the person being vaccinated. I have been given, and understand the information provided to me regarding the vaccine I have selected and the possible side effects. If I have further questions, I will ask the immuniser before I am immunised. I consent to receiving the vaccine chosen in question 1. I understand I must remain within the pharmacy premises for a period of 15 minutes post vaccination for observation and so that I may receive additional medical attention, including emergency care if needed. I have been advised of and agree to pay the charges associated with this service. I consent to a copy of my statement of immunisation being provided to my nominated medical practitioner.
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