ACH Vaccination Consent Form – Fremantle Ports "*" indicates required fields Personal DetailsName* First Last Department / Site*FremantleKwinanaDate of Birth* DD slash MM slash YYYY PhoneEmail Address Street Address City State / Province / Region ZIP / Postal Code Medicare Card Number*Medicare Expiry Date*Individual Reference Number*Number on Medicare card next to your nameEmergency ContactName First Last PhoneImportant QuestionsHave you fainted previously after an injection?* Yes No Are you on a blood-thinning agent e.g. warfarin?* Yes No Do you have a history of Guillain-Barre syndrome?* Yes No Are you pregnant or planning a pregnancy?* Yes No Do you have a disease that lowers immunity (e.g. Leukemia, Cancer, HIV/AIDS) or receiving treatment that lowers immunity (e.g. Oral Steroid medicines such as cortisone and prednisone, radiotherapy, chemotherapy)?* Yes No Do you have a severe allergy? (e.g. eggs)* Yes No Have you previously reacted to a vaccine?* Yes No Are you unwell with a fever?* Yes No Have you had any vaccine in the last month?* Yes No Have you received an injection of immunoglobulin or any blood products in the last year?* Yes No Are you living with someone who has a disease that lowers immunity or who is receiving treatment that lowers immunity?* Yes No If you answered yes to any of the above, please provide details below:ConsentConsent* I give consent to receive the vaccinationConsent* I give consent to Aspen Corporate Health to access my Australian Immunisation Register for the purpose of checking my vaccination statusConsent* I authorise Aspen Corporate Health to release a copy of my vaccination record to my employerConsent* I authorise Aspen Corporate Health to release a copy of my vaccination record to the Australian Immunisation RegisterUntitledFirst ChoiceSecond ChoiceThird Choice
