Flu Vaccine

Whitethorn Centre, Kilcoole, Co. Wicklow, A63 AK27

Your details

Full name (required)

Date of birth (required)

Contact number (required)

Address (required)

Gender (required)

PPSN (required)

GP name (required)

GP address (required)

Flu Vaccination

Are you under the age of 18? (Under 18 getting Fluenz nasal spray)

YesNo

Are you pregnant?

YesNo

Have you had breast surgery?

YesNo

Do you feel unwell in any way?

YesNo

Are you allergic to eggs or chicken?

YesNo

Have you ever had an allergic reaction to any previous vaccination?

YesNo

Are you allergic to any of the vaccine residues or excipients?

YesNo

Do you have a condition, or are you receiving treatment, that might affect your immune system? (if Chemo/Post Transplant, then recommend refer GP)

YesNo

Are you prone to fainting?

YesNo

Have you ever suffered an anaphylaxis attack?

YesNo

Please list any current medical conditions, medications or allergies (optional)

I have read and understood the 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 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

YesNo

I agree to proceed with the vaccination for Influenza

YesNo

I agree to have a record of vaccination stored in the pharmacy for 8 years

YesNo

Signature

Still to complete: Full name, Date of birth, Contact number, Address, Gender, PPSN, GP name, GP address, 13 questions, Signature, Security check.