Vaccine Forms

About the patient

First name

Last name

Date of birth For example 27 3 1985

Day

Month

Year

Gender

PPS number 7 numbers then 1 or 2 letters

Mobile number For example 087 123 4567

Address

County

Eircode (optional)

Country

GP name Your GP's name or practice Not registered with a GP

Risk factor (optional) Leave blank if none

Country of origin

Medical history

Answer yes or no to every question.

Is the patient over 18?

Yes No

Have you had the vaccine before?

Yes No

Are you pregnant?

Yes No

Have you had breast surgery?

Yes No

Are you suffering from a fever?

Yes No

Are you allergic to eggs or chicken?

Yes No

Have you ever had a reaction to any previous vaccine?

Yes No

Have you ever been recommended not to receive the flu vaccine?

Yes No

Have you ever suffered an anaphylaxis attack?

Yes No

Any heart, BP, asthma, diabetes or other medications?

Yes No

Medical history

Answer yes or no to every question.

Is the patient aged 2 to 17 years?

Yes No

Has the child had any flu vaccination before?

Yes No

Is the child unwell in any way (fever or acute infection)?

Yes No

Is the child allergic to eggs or chicken?

Yes No

Has the child ever had an allergic reaction to any previous vaccination?

Yes No

Is the child allergic to any of the vaccine residues or excipients?

Yes No

Has the child ever suffered an anaphylaxis attack?

Yes No

Does the child have any problems with their immune system?

Yes No

Does the child live with someone who is severely immunocompromised?

Yes No

Is the child taking aspirin/salicylate therapy?

Yes No

Has the child had an acute asthma attack in the last 3 days?

Yes No

Does the child require regular oral steroids or ICU care for asthma?

Yes No

Has the child had any antiviral medication in the last 2 days?

Yes No

Consent

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 Bradlon Pharmacies and shared with the HSE for the purposes of public health as required by legislation.

You'll sign the form at the pharmacy before your vaccination.

Consent

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 Bradlon Pharmacies and shared with the HSE for the purposes of public health as required by legislation.

Consent given by

Parent Guardian Self

The form is signed at the pharmacy before the vaccination.

Your Order

Flu vaccine consent forms

Which form do you need?

Which pharmacy are you going to?

About the patient

Medical history

Medical history

Consent

Consent

Your form has been sent

Your Order

Flu vaccine consent forms

1Which form do you need?

2Which pharmacy are you going to?

3About the patient

4Medical history

4Medical history

5Consent

5Consent

Your form has been sent

Which form do you need?

Which pharmacy are you going to?

About the patient

Medical history

Medical history

Consent

Consent