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Daithí Murray-Stokes *
Birdstown Schoolhouse, Burnfoot, Co. Donegal *
0868657207 *
04/01/2018 *
MM
/
DD
/
YYYY
PPS Number - 1205705BA *
Dr. Ciara Steele, Buncrana Medical Centre *
If under 9 years old and at-risk, has the child had any flu vaccination before? *
Required
Is the child unwell in any way (fever or acute infection)? *
Required
Is the child allergic to eggs or chicken? *
Required
Has the child ever had an allergic reaction to any previous vaccination? *
Required
Is the child allergic to any of the vaccine residues or excipients? *
Captionless Image
Required
Has the child ever suffered an anaphylaxis attack? *
Required
Does the child have any problems with their immune system? *
Required
Does the child live with someone who is severely immunocompromised? *
Required
Is the child taking aspirin/salicylate therapy? *
Required
Has the child had an acute asthma attack in the last 3 days? *
Required
Does the child require regular oral steroids or ICU care for asthma? *
Required
Has the child had any antiviral medication in the last 2 days? *
Required
Consent: I have read and understood the nasal influenza vaccination leaflet (https://backend-prod.medicines.ie/uploads/files/20200727%20PIL%20IE%20Fluenz%20Tetra%20Annual%20Strain%20Change%20INF%2020%200001%20MIL%20Removed_1596710014.pdf) and have been given an opportunity to speak to the pharmacist providing the vaccine. I understand:The nature of the treatment. The benefits and risks of immunisation. The risks of influenza. The possible side effects of vaccination, when they might occur and how they should be treated. I have been given an opportunity to ask questions and raise any concerns.I agree that the details I have supplied have been recorded and those records will be kept by Chemist Connect  and shared with the HSE for the purposes of public health as required by legislation. I agree to proceed with the nasal vaccination for influenza. PLEASE ENTER YOUR NAME BELOW TO CONFIRM CONSENT: Lucy Murray *
Daithí Murray-Stokes *
Birdstown Schoolhouse, Burnfoot, Co. Donegal *
0868657207 *
04/01/2018 *
MM
/
DD
/
YYYY
PPS Number - 1205705BA *
Dr. Ciara Steele, Buncrana Medical Centre *
If under 9 years old and at-risk, has the child had any flu vaccination before? *
Required
Is the child unwell in any way (fever or acute infection)? *
Required
Is the child allergic to eggs or chicken? *
Required
Has the child ever had an allergic reaction to any previous vaccination? *
Required
Is the child allergic to any of the vaccine residues or excipients? *
Captionless Image
Required
Has the child ever suffered an anaphylaxis attack? *
Required
Does the child have any problems with their immune system? *
Required
Does the child live with someone who is severely immunocompromised? *
Required
Is the child taking aspirin/salicylate therapy? *
Required
Has the child had an acute asthma attack in the last 3 days? *
Required
Does the child require regular oral steroids or ICU care for asthma? *
Required
Has the child had any antiviral medication in the last 2 days? *
Required
Consent: I have read and understood the nasal influenza vaccination leaflet (https://backend-prod.medicines.ie/uploads/files/20200727%20PIL%20IE%20Fluenz%20Tetra%20Annual%20Strain%20Change%20INF%2020%200001%20MIL%20Removed_1596710014.pdf) and have been given an opportunity to speak to the pharmacist providing the vaccine. I understand:The nature of the treatment. The benefits and risks of immunisation. The risks of influenza. The possible side effects of vaccination, when they might occur and how they should be treated. I have been given an opportunity to ask questions and raise any concerns.I agree that the details I have supplied have been recorded and those records will be kept by Chemist Connect  and shared with the HSE for the purposes of public health as required by legislation. I agree to proceed with the nasal vaccination for influenza. PLEASE ENTER YOUR NAME BELOW TO CONFIRM CONSENT: Lucy Murray *
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