Flu Vaccination Consent Form

I have read and understood the Influenza Vaccination Information Sheet supplied about the risks of Influenza vaccination including the risks of not being vaccinated. If I have any questions I will ask the immunisation provider prior to the vaccine being administered.
- Yes
- No
I will give relevant details of my medical history including conditions, allergies and/or medications (prescriptions or over the counter) to the vaccinator on the day of my Influenza Vaccination.
- Yes
- No
I request to be vaccinated against Influenza and I understand that this is completly voluntary and I can withdraw my consent at anytime prior to the vaccine being administered.
- Yes
- No
If you have any questions regarding this years Flu vaccination, please write your questions here. We will endeavor to contact you prior to your appointment (if possible) to answer these.
Print Name to Confirm your consent to be vaccinated