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Have you ever had a severe reaction or anaphylaxis following any vaccine component traces (formaldehyde, Octoxinil-9, sodium phosphate dibasic anhydrous, sodium phosphate monobasic anhydrous, eggs)? Yes No

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● The purpose, contra-indications and possible side-effects of this vaccination. ● It is my decision to be immunised with FluQuadri/Fluad Quad vaccination. ● The vaccine is administered according to recommendations of the National Health and Medical Research Council. ● That I must remain in the vicinity for 15 minutes after the vaccination. ● My records will be uploaded to the Australian Immunisation Register for future access. ● I will not proceed with vaccination if I have had a fever or felt unwell in the previous 24 hours of my planned vaccination. ● I have read the specific points about vaccine and frequently asked questions (FAQs)

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