Flu Vaccination Consent Form

Walthamstow Pharmacy Seasonal Influenza
Vaccination Consent Form
Patient's Details
First name*
Surname*
Address
Post Code
Telephone
Date of Birth*

DayMonthYear
NHS Number
GP Practice*
Patient's Emergency Contact
Name
Telephone
Relationship to patient
Patient's Consent
1. I agree to be given a flu vaccination by a trained pharmacist.
2. I confirm I have not already received a flu vaccination for this flu season.
3. I declare that the information I have given on this form is correct and complete.
4. I consent to the disclosure of relevant information, where appropriate, from this form to: my GP practice to help them provide care to me; and NHS England (the national NHS body that manages pharmacy and other health services) for the purposes of checking payments to the pharmacy and to allow them to make sure the service is being provided properly.
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Walthamstow Pharmacy Seasonal InfluenzaVaccination Consent Form