Nasal Flu Vaccination (Fluenz, ages 2-17)

Whitethorn Centre, Kilcoole, Co. Wicklow, A63 AK27

Date of birth (required)

Contact number (required)

Has your child ever received the flu vaccine before?

YesNo

Has your child already had a flu vaccine since 1 September 2026?

YesNo

Has your child ever had a severe allergic reaction to anything including medication or vaccines?

YesNo

If your child has had a severe allergic reaction to anything including medication or vaccines, please provide details (optional)

Has your child needed an Intensive Care Unit (ICU) admission following an allergic reaction to eggs?

YesNo

Has your child been diagnosed with asthma?

YesNo

If your child has asthma, does your child take regular steroids for their asthma and/or has your child ever been admitted to ICU/Critical Care for Asthma?

YesNo

Does your child take aspirin/salicylates medication?

YesNo

Does your child have a severely weakened immune system due to disease or treatment? e.g., leukaemia/lymphoma or high dose steroids or severe neutropenia

YesNo

Does your child live with anyone currently having treatment that severely affects their immune system? e.g., someone who has had a bone marrow transplant?

YesNo

If your child lives with someone whose treatment severely affects their immune system, please provide details (optional)

Does your child take medication called combination checkpoint inhibitors e.g., ipilumumab plus nivolumab?

YesNo

Is your child known to have a condition causing a Cerebrospinal Fluid (CSF) leak and/or has your child had a recent cochlear implant?

YesNo

Does your child have an inherited metabolic disorder?

YesNo

If your child has an inherited metabolic disorder, have you discussed whether your child can get the Nasal flu vaccine (LAIV) with your child's specialist medical team?

YesNo

If discussed, has your child's specialist medical team confirmed that your child can get the Nasal flu vaccine (LAIV)?

YesNo

Some children aged under 9 years who have never had a flu vaccine before will need to have a second dose of flu vaccine if they are at high risk of complications from infection with flu. If your child has never had a flu vaccine before and is aged under 9 years, they may need a second dose of flu vaccine if they have any of the following conditions: chronic heart disease; chronic liver disease; chronic neurological disease; chronic renal failure; chronic respiratory disease (including cystic fibrosis, moderate or severe asthma); diabetes mellitus; any condition that might mean they cannot breathe well (e.g., a spinal cord injury, seizure disorder, or other neuromuscular disorder); Down syndrome; cancer; immunosuppression due to disease or treatment including asplenia or hyposplenism; moderate to severe neurodevelopmental disorders such as cerebral palsy and intellectual disability.

Does your child have one or more of the conditions listed above?

YesNo

Before your child is vaccinated you should let your vaccinator know if your child: has had influenza antiviral medications in the 48 hours before their vaccine is due, they should not get the vaccine; has an acute exacerbation of asthma, including increased wheezing and/or needed additional inhalers in the previous 72 hours, they should not receive the nasal flu vaccine; has gotten a dose of the flu vaccine from their GP or Pharmacist since the consent form was completed, they should not get the vaccine; is unwell with a sudden fever (as vaccination should be delayed until recovery).

I have read and understood the Nasal Influenza (Fluenz) vaccination leaflet and have been given an opportunity to speak to the pharmacist providing the vaccine. I have been given an opportunity to ask questions and raise any concerns. I understand: the nature of the treatment; the risks of influenza; the benefits and risks of immunisation; the possible side effects of vaccination, when they might occur and how they should be treated. I agree that the details I have supplied have been recorded and those records will be kept by Mac Sherrys pharmacy and shared with the HSE for the purposes of public health as required by legislation.

I agree for my child to proceed with the vaccination for Nasal Influenza (Fluenz)

YesNo

Still to complete: School, Class, Teacher, Pupil name, Date of birth, Contact number, Parent/Guardian, Address, Gender, PPSN, GP name, GP address, 17 questions, Signature, Security check.