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Client Information
Confirm Details
What would you like to book?*
Adelaide Hills Council Clinic
Adelaide Hills Council Clinic
** required.
Please enter the vaccine required*
Please Select One
Please Select One
Under 5 year old scheduled vaccines
School catch up vaccination
Influenza vaccinations
Other
** required.
Employee ID
(optional)
Surname*
** required.
Given Name*
** required.
Date of Birth
(eg 7/01/1965)*
** required.
Gender*
Male
Female
Other
** required.
Phone Number*
** required.
Home Address
Suburb
State
Please Select One
Please Select One
SA
NT
WA
QLD
NSW
VIC
TAS
Postcode
Email Address*
** required.
* valid email required.
Do you identify as Indigenous or Torres Strait Islander?
Yes
No
Do you feel well and healthy today?
Yes
No
Have you ever had an influenza vaccination?
Yes
No
Have you ever had an allergic reaction to an influenza vaccination?
Yes
No
Are you allergic to eggs, egg products or feathers?
Yes
No
Allergies Details
Are you currently taking any blood thinning medication?
Yes
No
Have you had Guillain Barre Syndrome?
Yes
No
Are you aware you cannot drive for 30 mins after vaccination?
Yes
No
Please Select a Location and Date*
time_id
Appointment_Time
Booked
:
AHC Stirling - Council
Council Chambers
63 Mount Barker Road Stirling SA 5152
:
AHC Woodside - Council
Positive Ageing Centre
36 Nairne Road Woodside SA 5244
Thankyou for your booking, you will receive an email one (1) day prior to your appointment.
Please ensure you print the consent form you will receive on email and bring it with you on the day of the appointment.
For any queries or to cancel/change your booking please contact us on 1300 858 047.
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