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Consent Form for Influenza Vaccination

A Pharmacist who is a vaccinator must conduct final consent process and vaccine administration.

My Details

Fields marked with * are required

First Name

Family Name

Date of Birth

NHI Number (if known) NHI format is not valid.

Gender

Phone Number

Email Address Email address is not valid.

Your Address

Post Code

Ethnicity

GP Name

GP Phone Number

GP Address

Post Code

Consultation Questions

Answer
(Please select below)

Are you younger than 13 years of age?

Yes

Please consult your GP

Are you pregnant?

Yes

Please consult your GP

Are you 65 years of age or older?

If aged 65 years or older, you are eligible for a funded vaccination.

Yes

Are you younger than 65 years and have a chronic illness?
Click here for eligibility list.

Yes

Are you allergic to eggs or egg products?

Yes

Please consult your GP

Are you allergic to chicken proteins?

Yes

Please consult your GP

Are you allergic to Neomycin or other vaccine components?

Yes

Please consult your GP

Are you currently taking Warfarin?

Yes

Have you ever had a severe reaction to any vaccine?

Yes

Please consult your GP

Are you taking immunosuppressant medicines?

Yes

Please consult your GP

Have you had a severe allergic reaction from any cause?
(Excluding insect bites and bee stings)

Yes

Please consult your GP

Do you have any neurological conditions?
(Potential risk of recurrence of Guillain-Barre syndrome, neuritis, encephalomyelitis and other)

Yes

Please consult your GP

Create an Account

If you wish to retrieve and edit your Consent Form, you can create an account. To create an account enter your email address and a password. Passwords must have at least 8 letters, 1 number, uppercase and lowercase.

Email Confirm Email address is not valid.

Password Passwords must have at least 8 letters, 1 number, uppercase and lowercase.

Confirm Password Confirmation does not match.

(Please select boxes below)

I agree to Terms and Conditions?

By clicking Save you agree that Green Cross Health may from time-to-time contact you in relation to the services being provided under the Electronic Consent programme.

NHI Lookup

Matches (Select from below)

NHI

First Name

Surname

DOB

Phone

Address

FirstName

Surname

2/2/2015

0211116666

2213e Longname Street

FirstName

Surname

2/2/2015

0211116666

2213e Longname Street

Terms and Conditions

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