Flu Immunisation Consent Form

Flu immunisation consent form for the geographical pilot areas immunising 4 to 10 year-old children in 2013. Use this form in the United Kingdom for a approval of consent of Flu immunisation of your Child.

Flu Immunisation Consent Form

Parent/Guardian/Carer to complete
Please return this completed form to your child’s school by (date)

Student details

Surname: Forename(s): DOB:

NHS no (if known): Gender: Girl Boy Family doctor’s name:

Address and postcode: School name: Doctor’s address and postcode:

Phone number of parent/guardian/carer: Class/Form: Doctor’s phone number:

Important information about this immunisation which is given as a nasal spray

Has your child had a severe Has your child got a condition or are Is your child receiving salicylate therapy
(anaphylactic) allergic reaction to any they receiving treatment that makes (i.e. aspirin)? Yes No
previous vaccines? Yes No them immunosuppressed?
If ‘yes’ please provide details
Yes No
If ‘yes’ please provide details

If ‘yes’ please provide details

Does your child have a confirmed Does your child normally have his
egg allergy? Yes No or her flu vaccination at your GP’s
surgery? Yes No

Does your child have asthma? Is anyone in your family currently Is your child on any other regular
Yes No having treatment that severely affects medication? Yes No
their immune system (for example they
If YES, please tick level of their disease If ‘yes’ please provide details
need to be kept in special isolation)?
Mild Moderate Severe
Yes No

and record the daily medication they take:
If ‘yes’ please provide details

Has your child had an MMR vaccination Would you be happy to be contacted
in the last four weeks or are they due to find out what you thought about
one soon? Yes No the service? Yes No

Consent for immunisation for my son/daughter to receive the flu nasal spray

I have read and understood the information about the flu nasal spray Date:

YES, I CONSENT NO, I DO NOT CONSENT (Please give reasons on the back of this form.)

Do you consent to share information about your child’s immunisation with your GP, NHS and related organisations? Yes No

Name: Signature of


Pre-vaccination assessment for flu completed FLUENZ vaccine details

Child not immunised today because: Date given:

Not well enough today Allergies Asthma Batch number: Expiry date:

Refused (none given) Refused (partially given)
Vaccination administered by (print name):

Child suitable for immunisation:

Signature: Signature:

Flu Immunisation Consent Form