Vaccination Details Form Flu Vaccination Appointment Date* Date Format: DD slash MM slash YYYY This is the appointment date you have already made for your flu vaccinePersonal DetailsName* First Last Address* Street Address Address Line 2 City County Eircode Gender*MaleFemaleDate 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?Choose an optionDon't have a General PractitionerBeaumont Park Clinic, Beaumont Woods, Dublin 9Calderwood Family Clinic, 28 Sion Hill Road, Grace Park, Dublin 9Cremore Clinic, 66 Ballygall Road East, GlasnevinGlasnevin Family Practice, 11 Finglas Road, Hart's Corner, Glasnevin, Dublin 9Griffith Ave Practice, 411 Griffith Ave, Dublin 9Santry GP, Unit 1, Northwood House, SantryShanard Family Practice, 33 Shanard Road, WhitehallCollege Gate Clinic, 123 Ballymun Road, Dublin 9Whitehall Clinic, 394a Collins Ave, Dublin 9My GP Practice is not listedWe 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 NameManually 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?*YesNoAny 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 2 years and over and less than 16 years oldName of Parent / Guardian* First Last Address* Street Address Address Line 2 City County Eircode Contact No.Relationship to Patient*Choose an optionParentPlease specifyMedical HistoryHave you had breast surgery?*YesNoDo you feel unwell in any way?*YesNoIf 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?*YesNoHave you had a bone marrow transplant recently?*YesNoHas your child have severe neutropenia?*YesNoIs your child on regular oral steroids or were they admitted previously for a severe asthma attack to hospital?*YesNoIs your child regularly taking any aspirin / salicylates or currently taking any combination checkpoint inhibitors?*YesNoHas your child recently had an acute exacerbation of their asthma symptoms which resulted in increased wheezing and additional requirement of inhalers in the last 72 hours?*YesNoHas your child had any anti-viral medication in the previous 48 hours? in the*YesNoDoes your child live with anyone whom is severely immunosuppressed requiring isolation?*YesNoWhat 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?*YesNoDo you have a condition or are receiving treatment that might affect your immune system?*YesNoHave you / child received the flu vaccine previously for the 2019/2020 season?YesNoAre you taking any anticoagulants (blood thinners) / have a bleeding disorder?*YesNoI agree for a copy of my vaccination record form to be sent to my GP.*YesNoTerms 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 6 months-16 years of age as a Guardian /Parent to give consent when they are receiving their flu vaccination in the pharmacy. I acknowledge verbal consent will be given on the day of vaccination should I / child wishes to proceed with vaccination once all my queries have been answered satisfactorily. I also agree to wait in a designated area for 15 minutes post vaccination near the pharmacy for observation purposedPhoneThis field is for validation purposes and should be left unchanged.
