ACH Vaccination Consent Form – RAC WA

"*" indicates required fields

Personal Details

Please complete this form prior to your vaccination appointment.
DD slash MM slash YYYY
Number on Medicare card next to your name

Emergency Contact


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?*