Please read the Influenza Vaccination Information Form prior to consenting to receiving the Flu Vaccine. To access this Information Sheet, please click HERE
Flu Vaccine Consent Form
Step 1 of 2
First NameSurnameDate of BirthIf patient is a child, please enter weight.Are you a current patient of Pivotal Health?*
Home Address (if a new patient)*Contact Telephone Number (if not a current patient)Medicare Number (if not a current patient)Medicare Number number beside your name and expiry dateMedicare Number expiry dateHave you been vaccinated against flu in previous years?*YesNoHave you had a COVID vaccine within the last 14 days?*YesNoHave you experienced any reactions in the past to ANY vaccines?*YesNoHave you ever fainted after having an injection?*YesNoHave you ever suffered from Gullain-Barre syndrome (a rare severe nerve disorder)?*YesNoDo you have any allergies?*YesNoIf yes, please specifyAre you currently taking any medication?*YesNoIf yes, please specifyAre you pregnant or breastfeeding?*YesNo
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.
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.
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.
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
Cnr Shore and Wynyard Streets
Cleveland QLD 4163
P: 07 3286 1122
F: 07 3286 1133
For After Hours Care
Phone Hello Home Doctor on 134 100 or National Home Doctor Service 13 74 25 or 13 SICK