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Flu

Flu Shot Clinic – 2023

Student Name *

First

Last

House *

Date of Birth *

Parent/Guardian Name *

First

Last

Medicare Number / Issue Number *

Medicare Expiry *

By submitting this form I acknowledge that I have read and understand that:- *

It is with my consent that my son be immunised for influenza;
The immunisation is an injection of commercially available influenza vaccine;
The vaccine is administered according to recommendations of the National Health and Medical Research Council;
There is a low risk of a reaction or allergy to influenza vaccinations, as specified in the product information supplied by the manufacturer, as there are with all vaccinations.

HEALTH CENTRE ONLY

The below questions questions will be asked on the day of vaccination and will be filled in by TSS Health Centre Staff.

Do you have a fever or are you currently unwell?

No
Yes

Have you been vaccinated against influenza before?

No
Yes

Have you experienced any problems after any vaccination?

No
Yes

Are you allergic to chicken eggs?

No
Yes

Are you allergic to neomycin or polymyxin (type of antibiotic)?

No
Yes

Have you been diagnosed with Guillain-Barre Syndrome (condition of the nervous system) within 6 weeks of a previous influenza vaccination?

No
Yes

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An education at The Southport School does not simply focus on academic scores but frames the social and emotional development of the boy as essential to his development as a whole person.

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2 Winchester St
Southport QLD 4215
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Phone: 07 5531 9911
Email: [email protected]

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