top of page

Nasal Flu Vaccination Consent Form for children aged 2-17 years (Fluenz LAIV)

Part 1: Child’s Personal Details Complete this part for all children/young people

Birthday
Day
Month
Year

 Part 2: Parent/Guardian Personal Details

Birthday
Day
Month
Year

Part 3: Child’s Medical Details

1. Has your child ever received the flu vaccine before?
2. Has your child already had a flu vaccine since 1 September 2025
3. Has your child ever had a severe allergic reaction to anything including medication or vaccines?
4. Has your child needed an Intensive Care Unit (ICU) admission following an allergic reaction to eggs?
5. Has your child been diagnosed with asthma?
5a. If yes does your child take regular steroids for their asthma and/or has your child ever been admitted to ICU/Critical Care for Asthma?
6. Does your child take aspirin/salicylates medication?
7. 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
8. 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?
9. Does your child take medication called combination checkpoint inhibitors e.g., ipilumumab plus nivolumab
10. Is your child known to have a condition causing a Cerebrospinal Fluid (CSF) leak and/or has your child had a recent cochlear implant?
11. Does your child have an inherited metabolic disorder? If no skip to Part 4.

Please note that some children with inherited metabolic disorders may not be able to get the Nasal flu vaccine (LAIV). Children with inherited metabolic disorders will usually be attending a specialist medical team. Please ask your child’s specialist medical team whether your child should get the Nasal flu vaccine (LAIV) before you consent for the vaccine:

11a. Have you discussed whether your child can get the Nasal flu vaccine (LAIV) with your child’s specialist medical team?
11b. If yes, has your child’s specialist medical team confirmed that your child can get the Nasal flu vaccine (LAIV)?

Part 4: Vaccination Consent

Medical Consent: Please note only a parent or legal guardian can provide consent for a medical procedure, or refuse consent for a medical procedure for young people under 16 years of age. Young people aged 16 years or older are legally entitled to consent for themselves. If a young person aged 16 or 17 years old is unable to give informed consent then their parent or legal guardian can consent on their behalf. Read more about the HSE Consent Policy on the HSE website.

CONSENT TO VACCINATION: Please tick the box below and sign to give consent for vaccination.

By signing the below I confirm that:

• I have read and understand the accompanying vaccine information, including known side effects.

• I am authorised to give consent on behalf of the above named child. (young people 16 years or older are legally entitled to consent for themselves).

• I understand that LAIV Nasal flu vaccine is not recommended during pregnancy.

Please tick
Parent
Legal Guardian
Self

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

bottom of page