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Pharmacy QIV Influenza Vaccination Patient Consent Form

You can complete this form at the pharmacy on the day of your appointment, but why not save time? Fill it out online beforehand

Date of Birth
• Is the patient 6 months of age or older?
Yes
No
• If under 9 years old, have they had the vaccine before?
Yes
No
• Are you 60 years or older?
Yes
No
• Are you pregnant?
Yes
No
• Have you had breast surgery?
Yes
No
• Are you allergic to eggs or chicken?
Yes
No
• Have you ever had an allergic reaction to any previous vaccination?
Yes
No
• Are you allergic to any of the vaccine residues or excipients?
Yes
No
• Have you ever suffered an anaphylaxis attack?
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 Coombe Communitpharmacy and shared with the HSE for the purposes of public health as required by legislation.

I agree to proceed with the vaccination for Influenza for me/ child:
Yes
No
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