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CONTACT INFORMATION
Flu Vaccination Consent Form
Name *
e.g., Joe
Surname/Family Name *
e.g., Soap
Date of Birth *
Please choose from the calendar widget
Gender
Male
Female
Non-binary
Mobile Number *
e.g., 083 123 4468
Email Address *
e.g. joe.soap@hse.ie
Staff Group *
e.g., Nursing
Do you work directly with patients?
Yes
No
Is this the first time you have had the flu vaccine?
Yes
No
Don't know
Employer *
e.g., HSE CHO
Work location *
e.g., CHO3
County *
e.g. Limerick
Service *
e.g. Mental Health
Service Sub Grouping *
e.g. Mental Health Residential
Name of work location *
e.g. Limerick City Mental Health
Name of Ward/Department *
e.g. Phoenix Care
Please complete the following questions before signing the consent form
Are you suffering an acute illness
Yes
No
If yes please detail *
Have you ever had a sever reaction to anything including medication or vaccine
(Including anaphylaxis)
Yes
No
If yes please detail *
Do you have any illness or condition that increases your risk of bleeding?
Yes
No
If yes please detail *
Are you receiving treatment for cancer with medicines called combination checkpoint inhibitors?
e.g. ipilumumab plus nivolumab
Yes
No
If yes please detail *
I consent for vaccination with influenza vaccine *
I Consent
I have read and understand the accompanying vaccine information, including risks and side effects *
Yes
Signature *
Today's Date *
For Office Use Only
Date Given (dd/mm/yyyy)
Vaccine Name/ Manufacturer
Batch Number
Expiry Date
mm/dd/yyyy
Site Given
Vaccinators Signature and PIN/MCRN
Send
