Child Flu Immunisation Consent Form

This form must be completed at least 3 days before your child appointment or the appointment will be cancelled.

Child Flu Immunisation Consent - Westgate

Child's Details

Please use date format DD/MM/YYYY
Any responses will be sent to this email address

Please answer each of the following questions by ticking one box

Has your child had the Flu vaccine before?
Did they have nasal spray or injection?
Does your child have any medical conditions?
Is your child currently having treatment that affects their immune system (eg cancer treatment or high dose steroids)?
Is anyone in your household having treatment that severely affects their immune system?
Is anyone who regularly cares for your child having treatment that severely affects their immune system?
Has your child ever been admitted to hospital because of severe allergic reaction to eggs?
Is your child receiving salicylate therapy (e.g. aspirin)?
Has your child been diagnosed with asthma?
Has your child taken steroids in the last 2 weeks?
Has your child ever been in intensive care as a result of their asthma?
NB. The nasal flu vaccine contains products derived from pigs (porcine gelatine). There is no suitable alternative flu vaccine available for otherwise health children. More information for parents is available from www.nhs.uk/child-flu
I am the parent/guardian with parental responsibility for the above child and I consent for my child to receive the flu immunisation *
E.g. Monday AM/PM, Tuesday AM/PM