Flu Vaccine – Consent Form

Name
DD slash MM slash YYYY
Address

For those receiving HSE vaccine; Select one or more of the following

Consent

I have read and understood the Flu Vaccination Service leaflet. I have been given an opportunity to speak to the pharmacist providing the vaccine, to ask any questions and to raise any concerns. I agree that the details I have supplied will be recorded and kept in the pharmacy. I understand:
• The benefits and risks of immunisation.
• The risks of flu.
• The possible side effects of vaccination, when they might occur and how they should be treated.
• For patients under 16 years, consent must obtained from a parent/legal guardian

I confirm that the vaccine recipient is not allergic to any of the ingredients in the vaccine and I agree to proceed with the flu vaccination:
I agree for details of my vaccination to be sent to the HSE and to my GP
I agree to be contacted about the flu vaccine next year
DD slash MM slash YYYY

Medical History (if you are unsure of any answers, leave blank and discuss with the pharmacist)

Does the person receiving the flu vaccine feel unwell?
Have you ever had a serious allergic reaction to a vaccine, food or drug (including eggs, chicken or any of the vaccine ingredients listed overleaf)?
Are you currently receiving, or have you recently (in the last four weeks) received any cancer treatment?
Have you had breast surgery (or any procedure that removed lymph tissue from the breast/underarm area
Have you been diagnosed with severe neutropoenia (absolute neutrophil count <0.5 x 109/L)
Is the person receiving the flu vaccine pregnant?
Have you ever had an organ transplant or a stem cell transplant?

Additional questions for children:

Do they have severe asthma regularly requiring oral steroids or have they had increased wheezing or increased inhaler use in the past 72 hours?
Are they clinically immunodeficient or do they live with someone who is severely immunodeficient e.g. someone after a stem cell transplant
Are they on any salicylate therapy (e.g. aspirin)
Has the child received Influenza antiviral medication in the previous 48 hours?
If under 9 years old and at risk, has the child had the flu vaccine before?
This field is for validation purposes and should be left unchanged.

You can download and print this form as a PDF by clicking on the link below:

Allcare Flu Consent Form_PRINT

Phone

045 881146

Location

Vista Allcare Pharmacy,
Vista Primary Care,
Ballymore Eustace Rd,
Naas, Co. Kildare

Shop Email

vista@allcarepharmacy.ie

Opening Hours

M-S: 8 am – Midnight

Please note hours may change during the Christmas and New Years period hours

Contact Us

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