KPJ Ipoh Influenza Vaccine System Registration Form

IMPORTANT

Terms & Conditions:
Our drive-through Influenza vaccination package:

REMINDERS

Common side effects of influenza vaccine:

Drowsiness or tiredness
Muscle aches
Localised pain, redness and swelling at the injection site
Occasionally, an injection-site lump (nodule) that may last many weeks but needs no treatment
Low-grade fever (occuring in the first two days after vaccination)

You should NOT take the influenza vaccine if you:

are unwell and having fever
have history of severe, life-threatening allergies to flu vaccine or any ingredient in the vaccine
have history of Guillain-Barre syndrome

* required field

Name *

NRIC / PP No (without symbol - or space) *

Email *

Address *

Contact No (Home)

Contact No (Mobile) *

* Please ensure your contact number is reachable for confirmation of appointment

Vehicle registration No *

Appointment Date

* Your registered vehicle number will be recorded as the same car during drive thru vaccination given

By submitting this form, I declare that the above informations are correct and I have read and understood the terms & conditions provided.

Section A
1.	Do you have any of the following? *
a.	Fever	No	Yes
b.	Cough	No	Yes
c.	Running Nose	No	Yes

Section B
2.	Have you taken any influenza vaccine previously? *	No	Yes
2.	If "Yes", when is the date of last influenze vaccination: Date:	No	Yes
3.	Do you have any adverse reaction (e.g: rashes or breathing difficulties) due to influenza vaccine previously? *	No	Yes