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Consent Form for Shingles 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

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Gender

Phone Number

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Your Address

Post Code

Ethnicity

GP Name

GP Phone Number

GP Address

Post Code

Consultation Questions

Answer
(Please select below)

Are you under 50 years of age?(Zostavax only licensed in 50 years or over)

Yes

Please consult your GP

Have you had a shingles or zoster vaccination before? (in NZ in 2012 & from 2013 or in another country)

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 neomycin or gelatin?

Yes

Please consult your GP

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

Yes

Please consult your GP

Do you have any medical conditions that may affect your immunity? This includes problems with your bone marrow or blood, leukaemia, lymphoma and HIV/AIDS?

Yes

Please consult your GP

Are you taking medicines that affect the immune system?

Yes

Please consult your GP

Do you have active untreated tuberculosis?

Yes

Please consult your GP

Are you taking antivirals, e.g. acyclovir, famciclovir?

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.

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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.

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