FLU VACCINATION
RECORD/CONSENT FORM
Pharmacy Details
Pharmacy Name
GPhc Number
Address
Vaccine Administered by
Pharmacy Stamp
Date Administered
Postcode
Signature
Telephone
Patient Details
Name
Patients Doctor
Address
Surgery Address
Postcode
DOB
Telephone
NHS No (If known)
Existing Medical Condition
Current Medication
Allergies
Risk Group (See below)
Vaccine Details
Name
Manufacturer
Batch No
Expiry Date
Injection Site
Left Arm Deltoid
Right Arm Deltoid
Dose
Any adverse effects
Patient Consent
I agree to be given an influenza vaccine by a specially trained Pharmacist/Nurse
I have received a patient advice leaflet about influenza and vaccination
I confirm I have not been previously administered with a seasonal influenza vaccine for this coming winter
I understand that this information will be shared with my GP
I confirm that I am 18 years or older
Sign
Date
Risk Groups
R – Chronic Respiratory Disease
L – Chronic Liver Disease
H – Chronic Heart Disease
K – Chronic Renal Disease
D – Patient with Diabetes
N – Patient with Chronic Neurological Disease (Stroke/TIA)
P - Pregnant Women
C - Carers
O - Over 65s
A copy of this form must be kept within the pharmacy in accordance with good Governance policy. A photocopy should be sent to the patients GP