Vaccination consent

Mac Sherrys pharmacy

Both Covid-19 and Flu Vaccine

Your details
Covid-19 and Flu Vaccination
Are you over 60 years of age or have an underlying medical condition?
Are you under the age of 18? (Under 18 getting Fluenz nasal spray)
Are you pregnant?
Have you had breast surgery?
Do you feel unwell in any way?
Are you allergic to eggs or chicken?
Have you ever had Mastocytosis (extreme allergic reaction)?
Have you ever had an allergic reaction to any previous vaccination?
Are you allergic to any of the vaccine residues or excipients? (Trometamol/ polyethylene glycol (PEG))
Have you ever suffered an anaphylaxis attack?
Are you prone to fainting?
Have you ever had Periocarditis (inflammation of heart lining)?
Have you ever had Myocarditis (inflammation of heart muscle)?
Have you had COVID in the last 3 months?
Do you have a condition, or are you receiving treatment, that might affect your immune system? (if Chemo/Post Transplant, then recommend refer GP)
Do you have a bleeding disorder or on anticoagulants?
Have you had any other vaccines in the last 4 weeks?

I have read and understood the Covid-19 and Influenza vaccination leaflet and have been given an opportunity to speak to the pharmacist providing the vaccine. I understand: the nature of the treatment; the benefits and risks of immunisation; the risks of Covid-19 and Influenza; the possible side effects of vaccination, when they might occur and how they should be treated. I have been given an opportunity to ask questions and raise any concerns. I agree that the details I have supplied have been recorded and those records will be kept by Mac Sherrys pharmacy.

I consent for adrenaline to be administered should it be required due to an adverse reaction post vaccination
I agree to proceed with the vaccination for Covid-19 and Influenza
I agree to have a record of vaccination stored in the pharmacy for 8 years

Still to complete: Full name, Date of birth, Contact number, Address, Gender, PPSN, GP name, GP address, 20 questions, Signature, Security check.

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