Vaccination consent | Ashdown Pharmacy

Vaccination Consent form

Please fill out the following form to help us understand your needs and help you along when you visit us .

First Name

Telephone Number

PPSN Number:

Last Name

Date of Birth required

Sex

Postal / Zip code

Have you ever had a serious allergic reaction (to vaccines, PEG, trometamol or egg)? Required

Yes

Have you ever been diagnosed with Mastocytosis? Required

Yes

Have you ever had a bleeding disorder or are you on anticoagulation therapy? Required

Yes

Do you have a temperature today? Required

Yes

Have you recently completed chemotherapy or are you on checkpoint inhibitor treatment (eg ipilimumumab, nivolumab)? Required

Yes

Have you ever had myocarditis or pericarditis after a vaccine? Required

Yes

Have you had mpox vaccine in the last 4 weeks? Required

Yes

Are you immunocompromised or are you taking anti-virals? Required

Yes

Are you pregnant, if so have you received a vaccine in this pregnancy?

Yes

Have you had breastsurgery or are you at risk of lymphoedema? Required

Yes

Is this your first flu vaccine this season (sept-april) Required

Yes

Not Applicable

For Children Only: Do you take aspirin? Have you had to use a reliever inhaler in the last 3 days? Required

Yes

Not Applicable

I understand that the pharmacist is available to address any concerns I might have. A vaccine will take time to work and is not a guarantee that I will not later develop the condition, but the infection is far less likely to be severe. This vaccine may cause some injection site pain and redness. As with all medication, there is a small possibility of developing an allergic reaction to this vaccine. Flu, covid and pneumonia vaccines help prevent viral infections that can lead to headache, cough, long term fatigue, hospital stays and even death. The details that I have provided are accurate, these will be shared with the HSE and will be kept by the pharmacy for two years Required

Yes

I consent to receiving vaccination in Ashdown Pharmacy

Signature or Guardian Signature

Thank you for submitting