Information on Possible Reactions to the Vaccine Are Listed Overleaf

Information on Possible Reactions to the Vaccine Are Listed Overleaf

Diphtheria, Tetanus and Whooping Cough Immunisation (August 2012)

Please read both sides of this form very carefully
What is the Boostrix vaccine?
It is a vaccine containing Diphtheria, Tetanus and Pertussis(Whooping Cough) antigens.
Diphtheria is caused by bacteria which are found in the mouth, throat and nose. Diphtheria causes a membrane to grow around the inside of the throat. This can make it difficult to swallow and breathe. Diphtheria can be caught through coughs and sneezes from an infected person. / Tetanus
Tetanus is caused by a bacteria which are present in soils, dust and manure. Tetanus is a disease which attacks the nervous system. It causes muscle spasms first felt in the neck and jaw muscles. Tetanus can lead to breathing difficulties, convulsions and abnormal heart rhythms.
Whooping cough
Whooping cough, also known as Pertussis, is a highly
contagious disease which affects the air passages and breathing. The disease causes a severe, persistent cough and coughing spasms.
Whooping cough can be caught through coughs and sneezes from an infected person. Parents and family members are the main source of infection.

Information on possible reactions to the vaccine are listed overleaf.


Detach this consent slip and forward with your payment to:ordetach this slip and pay at one of Council’s

City of WhitehorseCustomer Service Centres*

Locked Bag 2

Nunawading Delivery Centre Vic 3131. *Please turn over for centre details

Name of person to be immunised (Print)......

Parent/Guardians name (for persons under 18 years)......


Suburb...... Post Code...... Phone No......

Date of Birth......

Amount to be paid - $51.00 (1 dose only required)

I hereby declare that I have read and understood the information attached to this consent slip and wish to have myself vaccinated against diphtheria, tetanus and whooping cough.

Signature of consent...... Date......

The personal information requested on this form is collected for the management of immunisation in accordance with the Public Health and Wellbeing Act. Your personal information will be included on the Australian Childhood Immunisation Register but will not be disclosed to any other party unless required by law. The information may also be used for the purpose of reminder letters or to ascertain your satisfaction with our services. You may access this information by contacting Council’s Environmental Health Unit on 9262 6197

RECEIPT PLEASE RC435 – Boostrix Vaccine

Before immunisation, please tell the doctor/nurse if you:
  • are unwell on the day of immunisation
  • have had a severe reaction to any vaccine
  • are pregnant ( the person to be vaccinated)
Common Side Effects:
  • Mild temperature ( below 39 C)
  • Pain, redness and swelling at the injection site
  • Feeling unwell
If these mild reactions occur, the symptoms can be reduced by:
  • Drinking extra fluids
  • Not overdressing
  • Applying a cold wet cloth on sore injection site
  • Taking paracetamol to reduce any discomfort
Most side effects are minor and quickly disappear. If they are more severe
or do not disappear please seek medical advice.
Extremely Rare Side Effects:
  • Brachial neuritis (severe pain, shoulder and upper arm)
  • Severe allergic reaction

Whitehorse Civic Centre
379-397 Whitehorse Road
Nunawading 3131 / Box Hill Service Centre
Box Hill Town Hall
1022 Whitehorse Road
Box Hill 3128 / Forest Hill Service Centre
Mon-Fri 9.00am-4.45pm
Sat 9.00am-12.00pm
T275 Level 2 (next to Big W)
Forest Hill Chase
Shopping Centre
Canterbury Road
Forest Hill 3131

If you have any queries regarding immunisation please contact the Environmental Health Unit on 9262 6197