Flu Vaccination Appointment Date*
Date Format: DD slash MM slash YYYY

This is the appointment date you have already made for your flu vaccine
Personal Details
Name*
First Last
Address*
Street Address Address Line 2 City County Eircode
Gender*
- Male
- Female
Date of Birth*
Date Format: DD slash MM slash YYYY
Your PPS Number*
Why do you need this personal detail? Legally we are required, as this is what the HSE use to identify you. We are obliged to notify the HSE of your vaccination administration through this process for record purposes.
What is the Name of the Practice of your General Practitioner?
We will notify your G.P that you have had a flu vaccination so they can note it on their records should you wish us to do so.
GP Practice Name
Manually enter the name of your GP Practice if it was not listed above.
Contact no:*
Email Address
Are you, or the person due to receive the flu vaccine under 16 years of age?*
- Yes
- No
Any parent or guardian who wishes to have their child (10 - 16 years of age) vaccinated against the Flu for the coming season will need to sign the consent form in-store when accompanying their child.
Parent/Guardian details if the Patient is 10 years and over and less than 16 years old
Name of Parent / Guardian*
First Last
Address*
Street Address Address Line 2 City County Eircode
Contact No.
Relationship to Patient*
Medical History
Have you had breast surgery?*
- Yes
- No
Do you feel unwell in any way?*
- Yes
- No
If you have a current temperature of 38 celsius or above it is advisable to postpone your vaccination until you are better.
Are you allergic to eggs?*
- Yes
- No
Have you had a bone marrow transplant recently?*
- Yes
- No
What date did your bone marrow transplant?*
Date Format: MM slash DD slash YYYY
Have you ever had a serious reaction to a vaccine or drug?*
- Yes
- No
Do you have a condition or are receiving treatment that might affect your immune system?*
- Yes
- No
Have you received the flu vaccine previously for the 2019/2020 season?
- Yes
- No
Are you taking any anticoagulants (blood thinners) / have a bleeding disorder?*
- Yes
- No
I agree for a copy of my vaccination record form to be sent to my GP.*
- Yes
- No
Terms and Conditions*
- I agree to the Terms of Service
Data Protection Notice: Personal data collected by this website and the HSE PCRS (Primary Care Reimbursement Service) is used for the purpose of providing a health service. It is required, stored, processed and disclosed to other bodies in accordance with the provisions of GDPR (General Data Protection Regulations) relating to proper treatment of personal data. I have answered all the questions above in a truthful and accurate manner. I agree to accompany a patient whom is 10-16 years of age as a Guardian /Parent to give consent when they are receiving their flu vaccination in the pharmacy.
Name
This field is for validation purposes and should be left unchanged.

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Parent/Guardian details if the Patient is 10 years and over and less than 16 years old

Medical History

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