Flu Vaccine Form Flu Vaccine Form Patient InformationHealth History Book an appointmentCovid-19 VaccineConsent Welcome to our Flu Vaccine FormFirst NameLast NameEmailPhone/MobileAddress Line 1CityPostcodeCountryUnited KingdomUnited Kingdom (UK)Date of birth Sex at birth Male FemaleEmergency Contact NameEmergency Contact Phone NumberPreviousNext Do you have any allergies to medications, foods, or vaccines (e.g., eggs, latex)? Yes NoPlease expand on the allergy and type of reaction Have you ever had a serious reaction to a vaccine in the past? Yes NoPlease explain your symptomsDo you have any chronic health conditions (e.g., asthma, diabetes, heart disease)? Yes NoPlease expand on your health conditionsAre you currently pregnant? Yes NoAre you currently breastfeeding? Yes NoDo you have a weakened immune system (e.g., HIV/AIDS, cancer, medications that affect the immune system)? Yes NoPlease detail your conditions Have you received any other vaccines in the past 4 weeks? Yes NoPlease detail the vaccines and when you took them Have you ever received the Influenza vaccine before? Yes NoPlease detail when you had itDo you have a bleeding disorder or are you taking blood-thinning medications? Yes NoPreviousNextWhich of the following exemption categories apply to you? No Exemption - Private Aged 65 or over Live in a care home Currently pregnant Acting as the main carer for an older or disabled person, or receiving a carer’s allowance Currently living with someone who has a weakened immune system Have one of the following long-term health conditions such as• heart conditions, such as coronary heart disease or heart failure• chronic kidney disease• liver disease, such as cirrhosis or hepatitis• some conditions that affect your brain or nerves, such as Parkinson's disease, motor neurone disease, multiple sclerosis or cerebral palsy• diabetes or Addison's disease• conditions that affect your breathing, such as asthma (needing a steroid inhaler or tablets), chronic obstructive pulmonary disease (COPD) or cystic fibrosis• a weakened immune system due to a condition such as HIV or AIDS, or due to a treatment such as chemotherapy or steroid medicine• problems with your spleen, such as sickle cell disease, or if you've had your spleen removed• being very overweight – a body mass index (BMI) of 40 or above• a learning disability (applies to flu only)• Severe mental illness: e.g. schizo or bipolar  (applies to Covid vaccine only)Select Appointment Date & TimeSelect Appointment Date & Time£18.50 - Private Flu Vaccine *Surbiton High School staff will be issued an invoice to claim back this cost from the school. PreviousNextDo you also want to book a COVID-19 vaccination? Yes, book COVID-19 vaccination No, only book a flu vaccinationSelect Appointment Date & TimeSelect Appointment Date & Time£90.00 - Private Covid VaccinePreviousNextVaccine Information and Consent Flu vaccine - Please read the following information carefully: Common side effects: Pain at the injection site, headache, fever, muscle aches, and mild fatigue. Serious side effects: Severe allergic reactions are rare but can occur. The Influenza vaccine is recommended to protect against the flu, a contagious respiratory illness caused by influenza viruses. The vaccine is usually given as an injection.Covid vaccine - Please read the following information carefully: Common side effects: Pain at the injection site, headache, fatigue, fever, muscle pain, chills, and nausea. Serious side effects: Severe allergic reactions are rare but can occur. The COVID-19 vaccine is recommended to protect against the coronavirus disease (COVID-19), a contagious respiratory illness caused by the SARS-CoV-2 virus. The vaccine is usually given as an injection in a series of doses, depending on the specific vaccine I have read the information about the Influenza vaccine. I understand the benefits and risks of the Influenza vaccine and request that the vaccine be given to me or to the person named above for whom I am authorised to make this request. I have read the information about the COVID-19 vaccine. I understand the benefits and risks of the COVID-19 vaccine and request that the vaccine be given to me or to the person named above for whom I am authorised to make this request.£0.00 for each month Previous Submit Form
