Vaccination Pre-Screening Form

Please fill out the following form prior to attending the pharmacy for your vaccination

First Name

Email Address

Last Name

Date of Birth

Please indicate if you:

Identify as Aboriginal or Torres Strait Islander

Are feeling unwell

Have a chronic illness

Are pregnant or planning to become pregnant

Have severe allergies

Have had a bleeding disorder

Have a disease or on medication that lowers immunity (Eg. HIV)

Have had recent vaccinations

Have ever fainted after having an injection

None of the above

Are you currently suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Medicare Number

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

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