top of page

Flu Vaccination Consent Form

The influenza vaccine has a strong safety record. It has been extensively studied, and there have been no reported deaths related to influenza vaccination in Malaysia or Singapore. Like other vaccines, the influenza vaccine may cause mild side effects such as redness, pain, and swelling at the injection site, or fever. These effects usually resolve on their own.

​

For more information about the vaccine, please refer to the following Vaccine Information: MIMS Vaccine Information

Enter your NRIC number WITHOUT dashes (’-’) / Masukkan nombor kad pengenalan anda TANPA tanda sempang (’-’).


Medical Information/ Maklumat Kesihatan

1. Have you received a flu vaccine before? Adakah anda pernah menerima vaksin flu sebelum ini?
Yes/ Ya
No/ Tidak
2. In the last 24 hours, have you had a fever (above 37.5°C) or are you feeling unwell? Adakah anda mengalami demam (>37.5°C) dalam 24 jam lepas?
Yes/ Ya
No/ Tidak
3. Have you ever had any side effects or issues after getting a flu vaccine or any other vaccines? Adakah anda mengalami kesan sampingan teruk (seperti sawan, pengsan) selepas mendapat mana-mana imunisasi/vaksin sebelum ini?
Yes/ Ya
No/ Tidak
4. Have you ever had a severe allergic reaction to vaccines, medications, insect stings, food, or anything else? Adakah anda mempunyai sejarah alahan teruk terhadap vaksin, ubat-ubatan, sengatan serangga, makanan, atau perkara lain?
Yes/ Ya
No/ Tidak


KAMICare

Integrating Health, Empowering Lives

bottom of page