Customer Satisfaction Survey
Charity of the Year
Prescription Collection Service
Serial Prescriptions (SRx)
Private Prescription Service
Prescription Messaging Service
Health Care Services
NHS Pharmacy First Scotland Service
Travel Health Clinic
Smoking Cessation Service
New Medicine Service
Common Clinical Conditions Clinic
Gluten-Free Food Service
Medicine Compliance Support
Maternity Tens Rental
You are here:
Flu Vaccination Questionnaire and Agreement
Flu Vaccination Questionnaire and Agreement
Please select your local Davidsons Pharmacy
Aberdeen - 340 Great Western Road
Aberfeldy - 7 Bank Street
Aboyne - Ballater Road
Alyth - 9 Airlie Road
Arbroath - 59 Keptie Street
Auchterarder - 54-56 High Street
Ballater - 10 Bridge Street
Banchory - 61-63 High Street
Blairgowrie - 21-24 Wellmeadow
Brechin - 41 High Street
Bridge of Earn - Main Street
Bridgend - 12-14 Main Street
Broughty Ferry - 120 Gray Street
Clackmannan - 30 Main Street
Comrie - Drummond Street
Crieff - 5 James Square
Drymen - 44 Main Street
Dundee - 92 Clepington Road
Dunkeld - 1 Bridge Street
Elie - 42 High Street
Forfar - 98 East High Street
Friockheim - 7 Gardyne Street
Garelochhead - Main Street
Killin - Main Street
Ladybank - 30 Commercial Road
Letham - 26B Blairs Road
McPherson Pharmacy - 120 Gray Street
Methven - 68 Main Street
Milnathort - 8-10 New Road
Muirhead - 117 Coupar Angus Road
Newburgh - 40 High Street
Panmurefield - Lawers Drive Panmurefield
Perth - 92-96 South Street
Pitlochry (new) - 65 Atholl Road
Pitlochry (old) - 112 Atholl Road
Portsoy - 1 Seafield St
Scone - 11-13 Angus Road
Stanley - 31 Percy Street
Strathblane - 10 SouthView Road
Thornton - 76 Main Street
Address Line 2
Date of Birth
What is your preferred contact method
Contact phone number
Have you ever had an allergic or anaphylactic reaction to an influenza vaccine or any other vaccine before?
If yes, please describe the reaction
Name of your GP and Surgery
Do you have any other allergies (e.g. egg, latex, antibiotics)?
If yes, please describe the allergy/reaction
Do you have a bleeding disorder, including taking any medications that thins your blood (anticoagulants)?
If yes, please state what medication you take
Could you be pregnant?
Do you feel any stress related reactions (e.g. feeling faint) when receiving a vaccine?
Have you had the flu vaccine before?
Have you had the flu vaccination within the last 180 days?
Are you eligible to receive a free flu vaccination, under the NHS?
Select eligible group from below if none apply please select no
No (we may still be able to provide you with a private vaccination service)
Aged 65 years or over (by 31st March 2021)
Aged 55 to 64 years (by 31st March 2021) NOTE: only eligible from December 2020
Chronic respiratory disease
Chronic heart disease
Chronic kidney disease
Chronic liver disease
Chronic neurological disease
Asplenia or dysfunction of the spleen
Unpaid carer or young carer
Household contact of immunocompromised individual
Morbid obesity (BMI ≥ 40)
Households of those shielding due to Covid-19
People aged 55 to 64 will not be vaccinated under the NHS scheme until December, and no appointments will be offered for this age group until then. This is to ensure that those who are most at risk are vaccinated first. If you wish to pay for a private vaccination please change your response to No.
Are you a frontline health or social care worker?
Location and role
I agree to be given a flu vaccination by a trained pharmacist.
I agree that information about my vaccination can be sent to my GP practice so they can update my health record.
I confirm I will read the information I receive from Davidsons Chemists before attending my appointment.
We will send your name, address and information about your flu vaccination to your GP practice so they can update your health record. We may send this completed form to NHS Health Board if they need to check our payments for providing this service. If they need to, this will allow them to contact you to check that we gave you a flu vaccination. If you have any queries about how we process your personal data or would like to exercise your rights under data protection legislation, please speak to a member of staff.
This field is for validation purposes and should be left unchanged.
Terms and Conditions
Customer Complaints Procedure
Freedom of Information
Modern Slavery Statement
Scroll to top
Content is protected !!
WP-Backgrounds Lite by InoPlugs Web Design
Juwelier Schönmann 1010 Wien
Send to Email Address
Your Email Address