Microsoft word - mulitple-vaccination-consent

VACCINATION - CONSENT FORM

FULL NAME: . . .MEDICARE/DVA NUMBER : ………………. ……….
FACILITY: ……………………………………………………………………………. D.O.B: . . . . . .
General Information :
The flu is caused by a number of strains of the Influenza virus that are easily spread by infected droplets in the air
through close personal contact, coughing and sneezing. The annual influenza vaccination is designed to provide
protection against several severe strains of the virus that the World Health Organisation has identified to be prevalent
for that year. It provides protection in up to 90% of people for approximately 9 months. There is a new vaccination
brought out each year in about March or April. Residents of institutions are immunized for their own sake but also to
protect other residents who may be more vulnerable to the consequences of infection.
Pneumococcal vaccine is given to protect against pneumonia from the 23 most prevalent or invasive
pneumococcal types of Streptococcus pneumoniae, including the six serotypes that most frequently cause
invasive drug resistant infections. The first injection is given from age 65 by the community GP. It was
followed by a booster 5 years later. Recent recommendations are that the booster not be done.
ADT Booster stimulates the immune system to form antibodies that protect against diphtheria and tetanus.
Protection can be expected to last for up to ten years. Even small injuries can result in exposure to tetanus.
BEFORE CONSENTING TO RECEIVING VACCINATION, PLEASE ANSWER THE FOLLOWING QUESTIONS. THE
INFORMATION YOU PROVIDE BELOW IS PRIVATE AND CONFIDENTIAL AND WILL NOT BE USED FOR ANY OTHER
PURPOSE
Have you had the Flu Vaccination this year? YN Have you had the Flu Vaccination in previous years? YN Have you had the Pneumococcal vaccination? YN (this information may be available from your previous GP-) Have you ever felt faint after an injection or had reaction to any vaccine or any other injected substance? YN If YES, please Specify _____________________________________________ Are you allergic to the antibiotic neomycin or eggs or to any other substance? YN
If YES, please describe, ____________________________________________

Do you suffer from any diseases that weaken the immune system or are you
having treatment that lowers immunity (radiotherapy or chemotherapy)? YN Are you taking any medicines containing steroids? (e.g. Cortisone, Prednisone) YN
I also understand and agree that:
• My consent to the vaccination is completely voluntary. (Patients who object to vaccination, even if it has been
consented to by family member or guardian will not be forced to have the vaccination.)
• The information provided by me in this consent form is true and accurate;
• Vaccinations may cause symptoms including a sore arm, mild fever, tiredness or muscle aches;
• I will be given the opportunity to read the medical information relating to any vaccine and seek medical advice about
its contents on request and that the onus is on me to make this request.
• Should I wish to vary my consent in a particular year the onus is on me to inform the doctor before March of that
year.

I have read and understood the above information and
I consent to receiving an annual influenza vaccine injection. YN
I consent to receiving Pneumococcal vaccine if not previously immunised YN
I consent to receiving ADT if required YN

Signed . Date . . .
Please state if you are signing as guardian, POA or family member

Source: http://members.optuszoo.com.au/drjudith/Mulitple-VACCINATION-CONSENT.pdf