Flu Vaccination Questionnaire and Agreement

Please select your local Davidsons Pharmacy*

Name*

First Last

Address*

Street Address Address Line 2 Postcode

Date of Birth*

DD

MM

YYYY

What is your preferred contact method*

Email
Phone
Text

Contact phone number*

Email*

Have you ever had an allergic or anaphylactic reaction to an influenza vaccine or any other vaccine before?*

Yes
No

If yes, please describe the reaction

Name of your GP and Surgery*

Do you have any other allergies (e.g. egg, latex, antibiotics)?*

Yes
No

If yes, please describe the allergy/reaction*

Do you have a bleeding disorder, including taking any medications that thins your blood (anticoagulants)?*

Yes
No

If yes, please state what medication you take*

Could you be pregnant?

Yes
No

Do you feel any stress related reactions (e.g. feeling faint) when receiving a vaccine?*

Yes
No

Have you had the flu vaccine before?*

Yes
No

Have you had the flu vaccination within the last 180 days?*

Yes
No

Are you eligible to receive a free flu vaccination, under the NHS?*

Select eligible group from below if none apply please select no

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?*

Yes
No

Category*

Location and role*

Consent*

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.

Name

This field is for validation purposes and should be left unchanged.