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9/F, 1 Duddell Street, Central

Clifford Chance Influenza Consent Form

* Indicates required field

Name *

First

Last

Email *

Phone Number *

HKID *

Any acute or severe illness *

Yes No

Suffering from any illness (with or without fever) Such as upper respiratory tract infection, common cold, etc. *

Yes No

Allergy to egg or chicken protein, thimerosal, neomycin, formaldehyde or octoxinol-9 *

Yes No

Allergy to any drug or vaccination *

Yes No

Bleeding disorder *

Yes No

Suppressed immune system *

Yes No

Pregnant or possibly pregnant *

Yes No

If you answer “YES” to any of the above, please seek further advice from the doctor before receiving the vaccination.

Have you had the flu vaccine before? *

Yes No

I acknowledge that these could be possible side-effects of vaccination:- local reaction (at injection site), erythema (redness), swelling, pain, systemic or generalised reaction, fever, headache and malaise. I will seek further advice from my doctor if these reactions last longer than 24 hours.

I hereby confirm I have read and consent to the above *

Yes No

Submit

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