Consumer Vaccination Pre-Screening/
Consent & Recording Form

Personal Details (Person to be Vaccinated)

*Supplying your medicare number speeds up the process to update the AIR register

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 understand:

- 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***