Nasal Influenza (LAIV) VaccinationConsent Form For children aged 2-17 yrsCommentsThis field is for validation purposes and should be left unchanged.Patient DetailsSurname(Required)Forename(Required)Address(Required) Address Line 1 Address Line 2 City County Eircode School(Required)Class(Required)Date of Birth(Required)Gender(Required)Select...MaleFemaleOtherPPSN(Required)GP(Required)GP Address(Required)GP Phone Number(Required)Parent / GuardianFull Name of Parent / Guardian(Required)Contact Number(Required)Email(Required) Medical HistoryIs the patient aged 2-17 years?(Required) Yes NoHas the child had any flu vaccination before?(Required) Yes NoIs the child unwell in any way (fever or acute infection)?(Required) Yes NoIs the child allergic to eggs or chicken?(Required) Yes NoHas the child ever had an allergic reaction to any previous vaccination?(Required) Yes NoIs the child allergic to any of the vaccine residues or excipients?(Required) Yes NoHas the child ever suffered an anaphylaxis attack?(Required) Yes NoDoes the child have any problems with their immune system?(Required)( e.g. stem cell / bone marrow transplant) Yes NoDoes the child live with someone who is severely immunocompromised?(Required) Yes NoIs the child taking aspirin/salicylate therapy?(Required) Yes NoHas the child had an acute asthma attack in the last month?(Required) Yes NoHas the child had any antiviral medication in the last month?(Required) Yes NoHas the child already had a flu vaccine this year?(Required) Yes NoIs your child known to have a condition causing a Cerebrospinal Fluid (CSF) leak and/or has your child had a recent cochlear implant?(Required) Yes NoIs the patient pregnant?(Required) Yes NoPlease add any further information or details based on the questions aboveConsentI have been given an opportunity to ask questions and raise any concerns.I agree that the details I have supplied have been recorded and those records will be kept by CDC Medical Clinics.I agree for my child to proceed with the nasal vaccination for influenza:(Required) Yes NoI agree for a copy of my child’s vaccination record form to be sent to the GP:(Required) Yes NoName of Parent/ Guardian(Required)Date Day Month Year Consent(Required)I understand:The nature of the treatment.The benefits and risks of immunisation.The risks of influenza.The possible side effects of vaccination when they might occur and how they should be treated. I have been given an opportunity to ask questions and raise any concerns. I agree that the details I have supplied have been recorded and those records will be kept by CDC Medical Clinics. I have read and understood the nasal influenza vaccination leaflet.
