Home

Consent Form for Conjugate Meningococcal Vaccination

A trained and qualified pharmacist vaccinator must conduct the pre-vaccination consultation, consent process and vaccine administration.

My Details

Fields marked with * are required

First Name * First Name is required

Family Name

Date of Birth *

Date of Birth is required

NHI 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 under 16 years of age or over 55 years?

Yes

Please consult your GP

Have you had a Meningococcal vaccination in the last five years?

Yes

Please consult your GP

Have you ever had a severe reaction to any vaccine?

Yes

Please consult your GP

Are you seriously allergic to anything including rubber latex? Excluding food allergies or bee strings

Yes

Please consult your GP

Are you allergic to formaldehyde, aluminium?

Yes

Please consult your GP

Had Guillain Barre syndrome before?

Yes

Please consult your GP

Are you taking anticoagulants (e.g. warfarin) or have bleeding problems?

Yes

Please consult your GP

Are you taking immunosuppressant medicines or do you have immune deficiencies?

Yes

Please consult your GP

Are you or could you be pregnant?

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.

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.

Terms and Conditions

SimplHealth