ACH Vaccination Consent Form – Fremantle Ports

"*" indicates required fields

Personal Details

Name*
DD slash MM slash YYYY
Address
Number on Medicare card next to your name

Emergency Contact

Name

Important Questions

Have you fainted previously after an injection?*
Are you on a blood-thinning agent e.g. warfarin?*
Do you have a history of Guillain-Barre syndrome?*
Are you pregnant or planning a pregnancy?*
Do you have a disease that lowers immunity (e.g. Leukemia, Cancer, HIV/AIDS) or receiving treatment that lowers immunity (e.g. Oral Steroid medicines such as cortisone and prednisone, radiotherapy, chemotherapy)?*
Do you have a severe allergy? (e.g. eggs)*
Have you previously reacted to a vaccine?*
Are you unwell with a fever?*
Have you had any vaccine in the last month?*
Have you received an injection of immunoglobulin or any blood products in the last year?*
Are you living with someone who has a disease that lowers immunity or who is receiving treatment that lowers immunity?*

Consent

Consent*
Consent*
Consent*
Consent*