I confirm and agree the following:          

1. I am at least 16 years of age.
2. I understand that the vaccine is subject to availability.   
3. I have read the Consumer Medicine Information (CMI) sheet for this vaccination 
4. I have read and understand information on precautions, contraindications and side effects (listed in each CMI and below), am aware of and accept any risks associated with the Vaccination and to my knowledge I do not suffer from any condition or circumstance that prevents me from having the Vaccination or makes it unsafe for me.
5. I will answer truthfully if the nurse asks for specific information about my health, past vaccinations or other conditions that may affect my participation.   
6. I will immediately inform the nurse of any adverse changes I experience in the course of participating in the Vaccination or afterwards, including (but not limited to): discomfort, pain, dizziness, shortness of breath, wheezing, difficulty breathing, swelling of the face, lips, tongue or other parts of the body.  
7. I understand that my vaccination status may be shared with my employer or educational institution, if required by law.  
8. I understand that as part of receiving the flu vaccine, my data will be recorded in the Aotearoa Immunisation Register (AIR). For further information Aotearoa Immunisation Register (AIR)                

Precautions and Contraindications

I agree to let the nurse know prior to the Vaccination if I:

• have had an allergic reaction to any previous vaccine   
• have recently had any other vaccine (e.g. COVID-19 vaccine)   
• are allergic to the active ingredients or any other ingredients in the vaccines  
• are suffering from an acute illness (e.g. an infection) or have a temperature higher than 38.5ºC  
• have or have had an immune response or low immunity problem e.g. a disorder, corticosteroid, cyclosporin or cancer treatment (including radiation therapy)  
• have or had allergies or allergic reactions e.g. itchy rash/hives, swelling of face, lips, mouth or tongue  
• have a bleeding problem or bruise easily  
• have ever fainted before, during or after having an injection  
• have a known allergy to egg protein  
• have a known allergy to latex, foods, preservatives or dyes  
• intend to become pregnant, are pregnant or breast-feeding   
• have or have had Guillain-Barré Syndrome (an illness which affects the nervous system and can cause severe muscle weakness or paralysis) after getting a flu vaccine. 

         
 I understand that having one of these issues may not prevent me from having the flu vaccine, but having a discussion with the nurse beforehand will allow me to make an informed choice about vaccination. 

Side effects   

I understand that, like all medicines, these vaccines may have some mild side effects, such as pain, tenderness, redness, swelling, bruising and hardness at the injection site, flu-like symptoms such as headaches, muscles aches, sore throat, cough, fever and chills/shivering or other symptoms like nausea, vomiting or diarrhoea.  

I understand that these symptoms do not mean I am sick, they are most likely to be my body’s natural response to the vaccine. The vaccine cannot give me an illness as it does not contain any live virus. The vaccine is generally well tolerated however I should stay close by so that the nurse can keep an eye on me for 15 minutes after the vaccine.                        

I confirm and agree the following:          

1. I am at least 16 years of age.
2. I understand that the vaccine is subject to availability.   
3. I have read the Consumer Medicine Information (CMI) sheet for this vaccination 
4. I have read and understand information on precautions, contraindications and side effects (listed in each CMI and below), am aware of and accept any risks associated with the Vaccination and to my knowledge I do not suffer from any condition or circumstance that prevents me from having the Vaccination or makes it unsafe for me.
5. I will answer truthfully if the nurse asks for specific information about my health, past vaccinations or other conditions that may affect my participation.   
6. I will immediately inform the nurse of any adverse changes I experience in the course of participating in the Vaccination or afterwards, including (but not limited to): discomfort, pain, dizziness, shortness of breath, wheezing, difficulty breathing, swelling of the face, lips, tongue or other parts of the body.  
7. I understand that my vaccination status may be shared with my employer or educational institution, if required by law.  
8. I understand that as part of receiving the flu vaccine, my data will be recorded in the Aotearoa Immunisation Register (AIR). For further information Aotearoa Immunisation Register (AIR)                

Precautions and Contraindications

I agree to let the nurse know prior to the Vaccination if I:

• have had an allergic reaction to any previous vaccine   
• have recently had any other vaccine (e.g. COVID-19 vaccine)   
• are allergic to the active ingredients or any other ingredients in the vaccines  
• are suffering from an acute illness (e.g. an infection) or have a temperature higher than 38.5ºC  
• have or have had an immune response or low immunity problem e.g. a disorder, corticosteroid, cyclosporin or cancer treatment (including radiation therapy)  
• have or had allergies or allergic reactions e.g. itchy rash/hives, swelling of face, lips, mouth or tongue  
• have a bleeding problem or bruise easily  
• have ever fainted before, during or after having an injection  
• have a known allergy to egg protein  
• have a known allergy to latex, foods, preservatives or dyes  
• intend to become pregnant, are pregnant or breast-feeding   
• have or have had Guillain-Barré Syndrome (an illness which affects the nervous system and can cause severe muscle weakness or paralysis) after getting a flu vaccine. 

         
 I understand that having one of these issues may not prevent me from having the flu vaccine, but having a discussion with the nurse beforehand will allow me to make an informed choice about vaccination. 

Side effects   

I understand that, like all medicines, these vaccines may have some mild side effects, such as pain, tenderness, redness, swelling, bruising and hardness at the injection site, flu-like symptoms such as headaches, muscles aches, sore throat, cough, fever and chills/shivering or other symptoms like nausea, vomiting or diarrhoea.  

I understand that these symptoms do not mean I am sick, they are most likely to be my body’s natural response to the vaccine. The vaccine cannot give me an illness as it does not contain any live virus. The vaccine is generally well tolerated however I should stay close by so that the nurse can keep an eye on me for 15 minutes after the vaccine.