Date of Birth:
Select venue for vaccination: —Please choose an option—Bendigo (May)FlemingtonCranbourneCaulfieldWarrnamboolWangarattaTerangGeelongBendigoPakenhamMorningtonBallaratKilmore
1. Do you have a servere allergy to eggs? YesNo
2. Are you suffering an acute illness with fever (>38.5°C) at present? YesNo
3. Have you ever had a reaction to the influenza vaccine in the past? E.g. Allergy, anaphylaxis, rash, hives YesNo
4. Have you ever felt faint or fainted after an injection or giving blood? YesNo
5. Do you have a history of Guillain-Barré syndrome. (Nervous Disorder) YesNo
Do you give consent to receive the influenza vaccine? I understand by giving consent to receiving the influenza vaccine I agree to stay within the immediate vicinity of the health professional for 15 minutes after my vaccination. Yes, I consent to receive vaccination
It is recommended by the Chief Health Officer that there should be at least 14 days between any vaccinations. It is also recommended that a flu vaccination is not taken in between the two shot COVID-19 vaccination
You must answer 'No' to the following two questions to be eligible for a flu vaccination.
I have NOT had a COVID-19 vaccination in the last 14 daysI am NOT awaiting my second COVID-19 vaccination
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