Pharmacy Influenza QIV Vaccination Patient Consent FormFill in your detailsMake an appointmentWe will confirm your appointmentFill in your detailsMake an appointmentWe will confirm your appointment Section 1: Personal Details Gender (indicate)MaleFemale Section 2: Medical History Is the patient 6 months of age or older? yesno If under 9 years old, have they had the vaccine before? yesno Are you 65 years or older? yesno Are you pregnant? yesno Have you had breast surgery? yesno Do you feel unwell in any way? yesno Are you allergic to eggs or chicken? yesno Have you ever had an allergic reaction to any previous vaccination? yesno Are you allergic to any of the vaccine residues or excipients? yesno Have you ever suffered an anaphylaxis attack? yesno Please list any current medical conditions, medications or allergies: Section 3: Vaccination Details Please select your local pharmacy Select Local PharmacyLavelle’s Life Pharmacy BelmulletLavelles Pharmacy Galway 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 #9379992 pharmacy and shared with the HSE for the purposes of public health as required by legislation. I agree to proceed with the vaccination for Influenza: I agree for a copy of my vaccination record form to be sent to my GP:
