Consumer vaccination pre screening consent recording form 2025

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53 votes

The document is a Consumer Vaccination Pre-Screening and Consent Form for administering the influenza vaccine. It collects personal information, assesses vaccination needs and general health suitability, and includes a consent section where the consumer agrees to receive the vaccine. The form also requires pharmacy details and records of the vaccination administered.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your personal information, including your name, address, phone number, and date of birth in the designated fields.
Indicate any allergies you may have and provide the name and contact details of your general practitioner.
Answer the mandatory question regarding Aboriginal or Torres Strait Islander origin by selecting 'Yes' or 'No'.
For the Vaccination Needs Assessment section, tick 'Yes' for any applicable questions regarding immunity and health conditions.
In the General Health and Suitability for Vaccination section, answer all questions truthfully to ensure safety during vaccination.
Review the consent statement carefully. Sign and date it to confirm your agreement to receive the vaccine at the specified pharmacy.
Complete the Pharmacy Details section with relevant information about emergency response kits and authorized immuniser signatures.

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Versions	Form popularity	Fillable & printable
2019	4.9 Satisfied (47 Votes)
2014	4 Satisfied (53 Votes)

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