Flu Vaccination Consent Form
for 18 - 59 year olds

To register your interest in being contacted for a Flu Vaccine appointment in your preferred Healthwise Pharmacy, please fill in the following form.

    Pharmacy Influenza QIV Vaccination Patient Consent Form

    Personal Details

    Medical History - Answer Questions

    Please answer the following questions with a yes or no answer

    If yes, ineligible for vaccination as anaphylaxis following a previous dose of influenza vaccine or any of its
    constituents is a contraindication to vaccination. If no, GO TO NEXT QUESTION.

    If yes, those requiring non-live influenza vaccine who have had a previous ICU admission for a severe anaphylaxis
    to egg need to be referred for specialist assessment with regard to vaccine administration in hospital. If yes, go to
    Question 2b. If no, go to Question 3.

    If yes, GO TO NEXT QUESTION. If no, ineligible for vaccination

    If yes, they cannot get this vaccine presently, defer vaccination until recovery. If no, GO TO NEXT QUESTION.

    If yes, you cannot have the vaccine. They should not receive any influenza vaccines, because of a potential
    association with immune related adverse reactions. If no, GO TO NEXT QUESTION.

    If yes, they should not receive the influenza vaccine, to avoid an acute vaccine related febrile episode.
    They are ineligible for vaccination. If no, go to next question.

    If yes, go to Question 7. If no, please answer question 6b.

    If yes, Individuals with a bleeding disorder or receiving anticoagulant therapy may develop haematomas in
    intramuscular (IM) injection sites. Prior to vaccination, inform the recipient about this risk. For those with
    thrombocytopenia (platelet count <50x10³), consult the supervising consultant. Proceed if fits clinical criteria.
    If no, go to question 8.

    If yes, then defer flu vaccine by at least one week from the PCV vaccine, if no, vaccination may
    proceed today.

    Please tick box to select any risks that apply. At least one Risk category must be present to qualify for Free Vaccination. Otherwise complete form for Private supply €30

    Consent

    I have read and understood the influenza vaccination leaflet and have been given an opportunity to speak to the pharmacist providing the vaccine.

    I understand:

    • The nature of the treatment.

    • The risks of influenza.

    • The benefits and risks of immunisation.

    • The possible side effects of vaccination, when they might occur and how they should be

    I have been given an opportunity to ask questions and raise any concerns.

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