Qualify. Is the patient aged 2-17 years? *
Vaccine is Free of Charge to those ages 2-17 years old.
1. Has your child ever received the flu vaccine before? *
2. Has your child already had a flu vaccine since 1 September 2025 *
3. Has your child ever had a severe allergic reaction to anything including medication or vaccines? *
3a.If yes, please provide details *
4. Has your child needed an Intensive Care Unit (ICU) admission following an allergic reaction to eggs? *
5. Has your child been diagnosed with asthma? *
5a. If yes does your child take regular steroids for their asthma and/or has your child ever been admitted to ICU/Critical Care for Asthma? *
6. Does your child take aspirin/salicylates medication? *
7. Does your child have a severely weakened immune system due to disease or treatment? e.g., leukaemia/lymphoma or high dose steroids or severe neutropenia *
8. Does your child live with anyone currently having treatment that severely affects their immune system? e.g., someone who has had a bone marrow transplant? *
8a.If yes, please provide details *
9. Does your child take medication called combination checkpoint inhibitors e.g., ipilumumab plus nivolumab? ? *
10. Is your child known to have a condition causing a Cerebrospinal Fluid (CSF) leak and/or has your child had a recent cochlear implant? *
11. Does your child have an inherited metabolic disorder? If Yes answer 11a and 11b. *
Please note that some children with inherited metabolic disorders may not be able to get the Nasal flu vaccine (LAIV). Children with inherited metabolic disorders will usually be attending a specialist medical team. Please ask your child’s specialist medical team whether your child should get the Nasal flu vaccine (LAIV) before you consent for the vaccine:
11a. Have you discussed whether your child can get the Nasal flu vaccine (LAIV) with your
11b. If yes, has your child’s specialist medical team confirmed that your child can get the
Information
Some children aged under 9 years who have never had a flu vaccine before will need to have a second
Chronic heart disease.
Chronic liver disease.
Chronic neurological disease.
Chronic renal failure.
Chronic respiratory disease (including cystic fibrosis, moderate or severe asthma).
Diabetes mellitus.
Any condition that might mean they cannot breathe well (e.g., a spinal cord injury, seizure disorder, or other
Down syndrome.
Cancer.
Immunosuppression due to disease or treatment including asplenia or hyposplenism.
Moderate to severe neurodevelopmental disorders such as cerebral palsy and intellectual disability.
Does your child have one or more of the conditions listed above? *
Before your child is vaccinated you should let your vaccinator know if your child:
has had influenza antiviral medications in the 48 hours before their vaccine is due, they should not get the
has an acute exacerbation of asthma, including increased wheezing and/or needed additional inhalers in
has gotten a dose of the flu vaccine from their GP or Pharmacist since the consent form was completed,
is unwell with a sudden fever (as vaccination should be delayed until recovery).
Consent
I have read and understood the nasal influenza vaccination leaflet and have been given an opportunity to speak to the pharmacist providing the vaccine.
I have been given an opportunity to ask questions and raise any concerns.
