Diphtheria/Tetanus/Polio Vaccine Form

Welcome to our Diphtheria/Tetanus/Polio Vaccine Form

Please fill out this form so your clinician can recommend the best treatment plan for you.

First Name

Last Name

Phone/Mobile

Address

Address Line 1

City

Postcode

Country

Date of birth

Sex at birth

Male

Female

Emergency Contact Name

Emergency Contact Phone Number

Select Appointment Date & Time

Vaccine Information and Consent

Please read the following information carefully:

The Diphtheria/Tetanus/Polio vaccine is recommended to protect against three serious diseases: diphtheria, tetanus, and polio. The vaccine is usually given as a series of injections.

Common side effects: Pain at the injection site, headache, fatigue, and mild fever.
Serious side effects: Severe allergic reactions are rare but can occur.

I have read the information about the Diphtheria/Tetanus/Polio vaccine. I have had an opportunity to ask questions which were answered to my satisfaction. I understand the benefits and risks of the Diphtheria/Tetanus/Polio vaccine and request that the vaccine be given to me or to the person named above for whom I am authorised to make this request.

Diphtheria/Tetanus/Polio Vaccine Form

Welcome to our Diphtheria/Tetanus/Polio Vaccine Form

Vaccine Information and Consent

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