Childhood Immunisation Consent form Name: _____________________________________________________ Vaccination event: (i.e. 3m or catchup) __________________________________________
NHI: _____________________ Date: ____________________
Health screen: Required for every vaccination event
Yes
No
Yes
No
Yes
No
Is your child feeling well today? Has your child had a fever in the past 48 hours? Any allergies? Has your child ever had a serious reaction to any vaccine? Has your child received any immunisations in the past month? Has your child seen a specialist doctor for any concerns?
Live vaccine additional questions: only ask when giving Priorix, Varivax or Zostavax Has your child had a blood transfusion / blood product injection in the past 12 months? Do you, your child, or anyone in the home have a medical condition or take any medication that might affect their immune system?
If parent/caregiver is not sure or answered yes to the 2nd live vaccine question, please ask these questions Does your child have, or has ever had cancer, leukemia, lymphoma, TB, HIV/AIDS, a transplant, stem cell therapy, or live with someone who does? In the last year has your child taken any steroids, anticancer or antiviral medications?
For infants under 12 months of age, did the mother take medications during pregnancy that may have affected her immune system? If answered yes to any of these last three questions - please get details and contact IMAC on 0800 466 863 to ask if vaccines can be given today or be deferred until another time
Pre-vaccination checklist, tick when completed ☐ ☐ ☐ ☐ ☐
Checked history of previous vaccines given (NIR/NIS) Health screen as above Discussed diseases and risks/benefits of the vaccines Post vaccination side effects discussed, and hand out given Informed consent obtained from parent or legal guardian
Name of parent/guardian: ___________________________________
Relationship: _________________
Signature of parent/guardian: ____________________________________
Date: ___________________
Vaccines given today: (please check catch up plan) Vaccine / diluent
Site
Batch
Expiry date