UniChem LifePharmacy Green Cross

Consent Form for Influenza Vaccination


A Pharmacist who is a vaccinator must conduct final consent process and vaccine administration.

My Details
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Consultation Questions

(Please select below)
Are you younger than 13 years of age?
Are you pregnant?
Are you 65 years of age or older?

If aged 65 years or older, you are eligible for a funded vaccination.
Are you younger than 65 years and have a chronic illness?
Click here for eligibility list.
Are you allergic to eggs or egg products?
Are you allergic to chicken proteins?
Are you allergic to Neomycin or other vaccine components?
Are you currently taking Warfarin?
Have you ever had a severe reaction to any vaccine?
Are you taking immunosuppressant medicines?
Have you had a severe allergic reaction from any cause?
(Excluding insect bites and bee stings)
Do you have any neurological conditions?
(Potential risk of recurrence of Guillain-Barre syndrome, neuritis, encephalomyelitis and other)


Create an Account
If you wish to retrieve and edit your Consent Form, you can create an account. To create an account enter your email address and a password. Passwords must have at least 8 letters, 1 number, uppercase and lowercase.

 
(Please select boxes below)


By clicking Save you agree that Green Cross Health may from time-to-time contact you in relation to the services being provided under the Electronic Consent programme.