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Consent Form for Whooping Cough (Tetanus-Diphtheria-Pertussis Booster) Vaccination

A Pharmacist who is a vaccinator must conduct final 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 18 years of age?

Yes

Please consult your GP

Is this your first time having tetanus vaccinations?

Yes

Please consult your GP

Have you had a pertussis 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

Have you had a severe allergic reaction from any cause? Excluding food allergies or bee stings

Yes

Please consult your GP

Are you allergic to formaldehyde, glutaraldehyde aluminium, or other vaccine components? (no egg)

Yes

Please consult your GP

Are you taking anticoagulants or have coagulation or bleeding problems?

Yes

Please consult your GP

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

Yes

Please consult your GP

Do you have any neurological condition?

Yes

Please consult your GP

Are you less than 28 weeks 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.

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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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