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 Influenza vaccine and the possible side effects. If I have further questions, I will ask the immuniser before I am immnuised. I consent to receiving the Influenza vaccine. I understand I must remain within the pharmacy premises for a period of 15 minutes post vaccination for observation and so that i mat 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.