Flu Vaccine 2022-2023

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Inactivated Influenza Vaccination Consent/appointment Form 2023-24

*Vaccine applicant must be at least TWO year of age.

Please Answer the following questions (Must be completed by parent/guardian if under 16)

Date of Birth:*

Full Name (With Title) :*

Sex :*

Email:*

Phone Number:*

Name and Address of GP:*

Complete Address and Postcode of applicant:*

Do you have a sever febrile illness or acute infection today? (Y/N) :*

Have you had the complete dose of flu vaccine this season? (Y/N) :*

Have you ever had a severe allergic reaction to Eggs/chicken protien/antibiotics/any previous vaccine? (Y/N):*

Do you Have any form of bleeding disorder or take any medicines that affect the way your blood clots?*

Is your immune system effected by a medical condition (i.e. HIV/AIDS) or medicines you take (i.e. steroids/chemotherapy)?):*

Are you pregnant or breastfeeding? (Choose not applicable if you are a male)*

Do you have any Allergies? (Latex, Antibiotics etc.) If Yes please describe otherwise type No*

Are you taking any Medication? (Over the counter/prescription), If yes please list below otherwise type No*

Date and time of Appointment required*

Concent to recieve the inactivated seasonal influenza vaccine*

I agree that, I (or representative) have provided the details above and have confirmed that they are correct and complete and that there are no contraindications that would prevent me from receiving an influenza vaccine today. I am aware of the potential side-effects and how to manage them. I understand that there is a small risk of a reaction to the vaccine and accept that the pharmacist is not responsible if they do have a reaction. I understand that having an influenza vaccine does not guarantee that they will not catch influenza this flu season.*

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What Makes The Wellness Pharmacy Different?

Our variety of Wellness Screening, helps an individual understand their health from within.

Covid-19 Screening and our health advice improves outcomes.

This helps our patients to understand the root causes of their problems and our Personalised Lifestyle Medicine approach not only helps them stay healthier but prevents chronic diseases in the future or improve their existing condition.

TOWER BRIDGE WELLNESS
43 SHAD THAMES
SE12NJ LONDON

Tel: +44 203 771 9927

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+447483380720

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