Personal Details (Person to be Vaccinated)
Primary Healthcare Provider (GP)
Pre Vaccination Screening Checklist
(reference: Australian Immunisation Handbook online)
Consent to receive immunisation
I understand I can request information regarding my vaccination, including possible side effects, from the pharmacy on the day of my appointment.
If I have further questions, I will ask the immuniser before myself/my child is immunised.
I consent to myself/my child receiving the
- I/my child must remain within the pharmacy premises for a period of 15 minutes after vaccination for observation and so that I may receive additional medical attention, including emergency care, if needed.
- This service will be recorded on the Australian Immunisation Register.
***Please note, you must book an appointment on the next page to secure your position***