DTP Vaccine Consent Form
Provides protection against Diphtheria, Tetanus and Pertussis

Client Consent Details(person being immunised)
First Name / Surname
Date of Birth / Gender(Please circle) / Male / Female
Medicare Card Number / ______ref ___
Address
Suburb / Postcode
Telephone
Declaration / (Please circle)
I haveread and understood the information provided and give permission for / myself / my child
to be immunised against Diphtheria, Tetanus and Pertussis.
Signature
(if under age of 18, parent/guardian signature required) / ______/ Date / ____ / ____ / ______
Please see the reverse side of this form for further information
IMMUNISATION USE ONLY
Dosage / 1 dose for persons aged 18 years or older
Cost / $49.00 per dose
Client Eligibility(Please circle) Please see reverse of this form for criteria / Free / Paid
Cardholders Name
Card Type(Please circle) / Eftpos / Visa / MasterCard
Receipt Number / Date / Amount Paid / $
/ COUNCIL OFFICE USE ONLY /
ABN 98 606 522 719 / RC - VACDTP / Receipt Number / Amount / $
/ FOR CLIENT /
Client Name:
Today you received a dose of the Diphtheria, Tetanus and Pertussis vaccine from Maroondah City Council Immunisation Service. Please retain this receipt for your records.
Date Given:
Important: Post vaccination, it is recommended that you remain at the immunisation venue for 15 minutes and do not drive for 30 minutes. / Office Use ONLY
Vaccine Brand
(Please circle) / Free / Paid

Information: Eligibility for FREE Vaccines in Victoria
Vaccine / Criteria
Diphtheria, Tetanus, Pertussis /
  • Pregnant women from 28 weeks gestation during EVERY pregnancy

  • Partners of women who are at least 28 weeks pregnant if the partner has not received a pertussis booster within the last 10 years

  • Parent/guardians of new babies that have not received a pertussis booster in the last 10 years

  • Young people 10 to 19 years of age, of families who currently receive family assistance payments, between 1st January 2016 to 31st December 2017

Last Updated June 2017

Maroondah City Council_ DTP Consent Form
Last Updated: June 2017QMS ID:Review Date: June 2018