Influenza Vaccination Consent Form
2015/16
Patient ID no
(you will find this no. on your repeat medication slip)
Patient Details
Please complete and Sign
Allergies
Please circle where appropriate
First Name …………………… Surname………………………..Date of Birth ………………………
Age Group:
64yrs and under
65yrs or over
Age 2-4yrs
Are you allergic to
chicken or eggs? Yes / No
Do you have any other
allergies? Yes / No
Patient Signature: …………………………………… Date Vaccine Given: …………………….
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For Completion by Nurse/GP administering the vaccine:
For Patients eligible for 2 doses
If Yes Please
of vaccine
pleaseindicate
circle to
what1…………………………
st or 2nd dose.
whether
1st Dose
2nd Dose
If patient is aged under 65years please indicate below a Clinical Risk/ reason for vaccine
Asthma
Carer
Immuno-suppressed
Asplenia
COPD
Diabetes
Liver Disease
Chronic Neurological Disease
Living in Nursing/Care home
Heart Disease
Pregnant
Kidney Disease
Healthcare Worker employed by the Practice
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I have explained the procedure to the patient. I have also discussed what the procedure is likely to involve, the
benefits and the risks of any alternative treatments (including no treatment) and any other particular concerns of the
patient.
Given by: ………………………………………………….. Batch No /Expiry Date ………………………. Left / Right Arm
No Clinical Risk identified for Flu vaccine
Date ………………………. Left / Right Arm