Don Medical Clinic - Flu Consent Form - 2020

Flu Vaccine Consent Form

Don Medical Clinic - Dedicated Mass Flu Immunisation Clinics - have now been completed for 2020.

IMPORTANT INFO - We Now only have availability of public funded flu vaccinations (We do not have any private vaccines available). If you complete this form and it indicates you are NOT eligible for the free vaccine, DO NOT Pay or book an appointment. You can email forms@donmedical.com.au and we can put you on a wait list. We cannot gurantee supply of additional flu vaccines at this stage so we suggest you check around.

Free Vaccines are currently available for the following people

1. aged 6 months to 5 years (Once the child turns 5 they are ineligible on this criteria)

2. aged 65 and over

3. Aboriginal and Torres Strait islander: 6 months and older.

4. Eligible Chronic disease - Heart, respiratory, cancer, Neurological,

5. Pregnant women

All Don Medical Flu vaccination visits are short visits purely for the vaccine. No other medical conditions will be discussed. These Visits will be bulk billed to Medicare. Currently these are only available for patients eligible for the "free" vaccine as listed above. .(If your employer has negotiated a private arrangement with Don Medical Clinic, your vaccine and consultation fee will be paid by your employer and you just need to complete this form only)

Step 1: Pre vaccination and consent form (below)- This must be completed prior to making your appointment as this will also determine if will need to pay for your flu shot or are eligible for agovernement funded vaccine. To keep a minimal amount of human contact with pens and paper we are using this online consent form this year. (see below). This form needs to be completed for EACH person in the family having the Flu vaccine. For children and patients under care, the parent or carer will need to complete, sign and submit this form for each person. Once this is completed you will receive an email to the Appointment booking page and to the Online payments page

Step 2: Appointment Booking - Due to COVID-19, we are currently running limited face to face consultations on a needs basis. If you require a Flu immunisation and are eligible for the "free" vaccine, Please call reception on 6441 5299 to arrange an appointment for this.

any issues please contact reception on

P: 03 6441 5299

E: reception@donmedical.com.au

Patient Full Name: *

Patient Date of Birth: DD-MM-YYYY *

Patient Email address: *

Patient Phone: *

Patient Address: *

Please enter your Medicare Number. (this is required as an identifier and also to allow adding this immunisation to the Australian Immunisation record) *

Please enter your Medicare "Individual Reference Number" (the number next to your name on the card) *

Your Medicare card expiry date. - MM/YYYY *

Please select whether you are a Private Patient, OR a Healthcare Home registered patient OR this has been organised for you as part of your workplace(Employer) arrangement with Don Medical Clinic *

Q1. Is the patient, aged between 6 months and 5 years old? *

Q2. Do you identify as Aboriginal or Torres Strait Islander? *

Q3. Are you aged 65 years or over? *

Q4. Are you Pregnant? *

Q5. Do You have any of the following medical Conditions?

Cardiac (heart) Disease
Chronic Respiratory (Breathing) conditions (eg Asthma COPD)?
Chronic Neurological condition (eg MS, Epilepsy)?
Immunocompromised (eg Cancer, HIV, Chronic steroid use)?
Diabetes?
Renal Disease?
Haematological (Blood) disorders?
Long term aspirin therapy in child under 10?

Did you answer "YES" to any of the questions Q1 to Q5 above? *

Have you ever had a flu vaccine previously? *

Have you had any problems/complications with previous flu vaccination? *

Have you had any severe allergies to anything in the past? *

Do you have a high fever or feel unwell? *

Do you have a history of Guillain Barre Syndrome(severe muscle weakness)? *

The flu vaccine is very safe and generally people have no reaction. The most common side effects are tenderness, swelling and redness at the injection site which usually disappears within a few days. A small percentage of people may experience a mild fever and feel unwell for a few days – this is not the flu. These symptoms clear up within a few days.

It is recommended that all people who receive the flu vaccination remain in the vicinity for 15 minutes in case of an allergic response. Do you agree to this? *

Today's Date: *

I have read and understood this information and I consent to receiving a flu vaccine injection. *

Signature: Please use your mouse (on a non touch screen) or mouse, finger or stylus on a touch device to enter your signature *

Your Message

Anti-Spam: 3 + 4 is: *

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This will include Links to the online Bookings page and the online payments page

If you are eligible for the Government funded(free) vaccine You will need to make a booking, please call reception on 6441 5299 to arrange an appointment for this vaccination.

Flu Vaccine Consent Form

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