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Seasonal influenza vaccination consent

Seasonal influenza vaccination consent

Information provided

Before completing this form, please ensure that you have:

  • received information about the seasonal influenza vaccination; and
  • been offered, or directed to, the manufacturer’s Patient Information Leaflet.

A registered healthcare professional will confirm your eligibility and assess whether vaccination is clinically appropriate before the vaccine is administered.

Consent questions

Please select Yes or No for each question.

Have you ever had a severe allergic reaction or anaphylaxis after a previous influenza vaccination or another vaccine?
Do you have a known allergy to any ingredient of the influenza vaccine being offered or have a severe egg allergy (causing anaphylaxis)?
Have you ever been told that you should not receive an influenza vaccine?
Have you previously experienced a significant reaction following vaccination that required medical assessment or treatment?
Have you received and understood information about the seasonal influenza vaccination?
Have your questions been answered sufficiently for you to make a decision?
Do you understand that vaccination is voluntary and that you can change your mind at any time before the vaccine is administered?

If you are unwell and have a fever (temperature) on the day of your vaccination appointment, please contact reception to reschedule your appointment.

Consent
Patient declaration