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Annual Influenza Vaccination

Consent and Pre-vaccination screening checklist

Next Practice WSIH

158-160 Hawkesbury Rd Westmead NSW 2145

P (02) 9145 1290

F (02) 8287 2529

E wsih@nextpracticehealth.com

   W https://nextpracticehealth.com/locations/nsw-westmead


Following vaccination- What to expect and what to do

All vaccinations may cause the following reactions:

  • Mild fever that doesn't last long <38.5°C 
  • Where the needle is given: Sore, red, burning, itching or swelling for 1-2 days and/or small, hard lump for a few weeks
  • Teenagers/adults fainting and muscle aches.

When to seek medical advice: 

  • Pain and fever are not relieved by paracetamol
  • The reactions are bad, not going away or getting worse or if you are worried at all
  • Any of the rare reactions below are experienced.

How to report an adverse reaction:

Significant events that occur following immunisation should be reported to your health professional. Alternatively you can report directly to the Therapeutic Goods Administration (www.tga.com.au) or by phone to the Adverse Events Medical Line on 1300 633 424. Calls are answered by a registered pharmacist.

Rare reactions requiring immediate medical attention

As with any medication, on rare occasions, an individual may experience a severe reaction. Seek medical attention if the below is experienced and inform of recent vaccination. 

Anaphylaxis

A severe allergic reaction which occurs suddenly, usually within 15 minutes, however anaphylaxis can occur within hours of a vaccine being administered. Early signs of anaphylaxis include redness and/or itching of the skin, swelling (hives), breathing difficulties, persistent cough, hoarse voice and a sense of distress. 


By ticking this you acknowledge that you have read and understood this information, that you have been offered the Consumer Medicine Information for your vaccine(s) (available at Next Practice WSIH) and that you consent to receiving vaccine(s) injection.

 

I Agree

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
This checklist helps decide about vaccinating you today. Please fill in the following information for your immunisation provider.
Please indicate if the person to be vaccinated:
is unwell today
has a disease that lowers immunity (eg leukaemia, cancer, HIV)
is having treatment that lowers immunity (eg oral steriod medicines such as cortisone and prednisone, DMARDs [disease -modifying anti-rheumatic drugs], other biologics/monoclonal antibodies, radiotherapy, chemotherapy)
has had a severe reaction following any vaccine
has any severe allergies (to anything)
has had any vaccine in the past month
has had an injection of immunoglobulin or received any blood products or a whole blood transfusion within the past year
is pregnant
has a history of Guillian-Barre syndrome
was a preterm infant
has a severe or chronic illness
has a bleeding disorder
identifies as an Aboriginial or Torres Strait Islander person
does not have a functioning spleen
is planning pregnancy or anticipating parenthood
is a parent, grandparent or carer of an infant < 6 months of age
lives with someone who has a disease that lowers immunity (eg leukemia, cancer, HIV) or lives with someone who is having treatment that lowers immunity (eg oral steriod medicines such as cortisone and prednisone, DMARDs [disease-modifying anti-rheumatic drugs], radiotherapy, chemotherapy)
is planning travel
has an occupation or lifestyle factor(s) for which vaccination may be needed (discuss with immunisation providers)
Please specify:
Note: Please discuss this information or any questions you have about vaccination with your immunisation provider before the vaccine(s) are given.
Before any vaccination takes place: *
Did you understand the information provided to you about vaccination?
Do you need more information to decide whether to proceed?
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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