Paid Flu Vaccination Consent Form

Name *

Email Address *

Date of Birth (dd/mm/yy) *

Address *

Possible side effects of flu vaccination include:

Pain
Redness and/or swelling at the injection site for a day or two
A mild fever
Muscle aches or headache within the first 2 days
Rarely an allergic reaction can occur

Please ensure the following statements are true

I am not suffering from an acute illness
I have never had a severe reaction to anything including medication or vaccine (including anaphylaxis)
I do not have any illness or condition that increases my risk of bleeding
I am not being treated for cancer with medicines called combination checkpoint inhibitors (e.g. ipilumumab plus nivolumab)

DO NOT COMPLETE THIS FORM IF ANY OF THE ABOVE ARE NOT TRUE - PLEASE CALL THE SURGERY

You should remain in the vicinity of the surgery for 15 minutes after your vaccination in case of an allergic response. Please advise us if you feel unwell after your vaccination.

For further information on the flu vaccine please read this HSE publication.

Please tick the box below to confirm your consent.

I have read and understand the vaccine information including the risks and side effects as described here. I consent for vaccination with the influenza vaccine.