Patient Name :

Patient Surname :

Date of birth :

Address :

Eircode :

Phone :

PPS Number :

Nationality :

Sex assigned at birth:
MaleFemale

GP Name :

GP Address :

Is the child aged 2 years or over?
YesNo

If the child is aged 2 to 8 years, are they in a clinically at-risk group?
YesNo

Does the child have severe asthma or have they been wheezy or needed their inhaler more than usual in the
past three days?
YesNo

Does the child live with a severely immunosuppressed person?
YesNo

Does the child have a severely weakened immune system because of certain medical conditions or
treatments?
YesNo

Is the child taking medicines called salicylates, which include Aspirin?
YesNo

Consent:

Please Tik the boxes if you are agree.
I consent to this information being shared with my doctor
I have read and understood the accompanying leaflet and I have been given an opportunity to speak to the pharmacist providing the vaccine.The information I have provided is correct to the best of my knowledge.The influenza vaccine will be only be offered if the Pharmacist believes it is appropriate to do so I consent to the recording and keeping of data pertaining to this service at Bria's Pharmacy.
I am happy to proceed with the vaccination for Influenza.