Personal Details

First name*

Last name*

Birthday*

Have you had a vaccination with us before?*

yes

If no, please provide the following:

PPSN

GP details

Contact Number

Address

Medical History

Are you pregnant?

yes

Have you had breast surgery?*

yes

Do you feel unwell in any way?*

yes

Are you allergic to eggs or chicken?*

yes

Have you ever had an allergic reaction to any previous vaccination?*

yes

Are you allergic to any of the vaccine residues or excipients?*

yes

Have you ever suffered an anaphylaxis attack?*

yes

Consent

I have read and understood the influenza vaccination leaflet and have been given the opportunity to speak to the pharmacist providing the vaccine.

I have provided the pharmacist with a list of my current medical conditions, medications and/or allergies

I understand:

The nature of the treatment

The benefits and risks immunisation
The risk of influenza
The possible side effects of vaccination, when they might occur and how they should be treated

I agree that the details I have supplied have been recorded and those records will be kept by Clonee Pharmacy and shared with the HSE for the purposes of health public health as required by legislation.

I have been given an opportunity to ask any questions and raise any concerns

I agree to proceed with the vaccination for influenza

Signature*

Consent form

Clonee Pharmacy
Unit 2 The Clonee Centre,

Main Street,

Clonee, Meath,

D15 NN5E, Ireland

Email:
info@cloneepharmacy.ie

Phone:
01 825 3019

Opening Hours:

Monday - Friday

09:00 - 19:00

Saturday

09:00 - 18:00

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