Vaccination Consent

Please complete before your appointment. It takes two minutes and helps us keep you safe.

Full name of the person being vaccinated (required)Date of birth (required)Address (required)Phone number (required)Which vaccination? (required)

Screening

Are you unwell today, or do you have a fever? (required)Have you ever had a serious reaction to a vaccine? (required)What happened, and to which vaccine?Allergies (required)

Do any of these apply? (required)

Medication you take

Consent

Vaccines commonly cause a sore arm, tiredness or a mild fever for a day or two. Serious reactions are rare, and we ask you to wait for a short observation period afterwards. Information about the specific vaccine will be given to you before it is administered.

I have been given, or have read, information about this vaccine (required)

I have had the chance to ask questions (required)

I agree to wait for the observation period afterwards (required)

I consent to receiving this vaccination (required)

If consenting for a child, your name and relationship