Flu-Vaccination-Record-And-Consent-Form - Psnc Page 2
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1
2To be completed by pharmacy staff
Any allergies
Aged over 65
Chronic respiratory disease
Eligible patient group*
Chronic heart disease
Chronic kidney disease
Chronic liver disease
Chronic neurological disease
Diabetes
Immunosuppression
Splenic dysfunction
Pregnant woman
Person in long-stay
Carer
residential or home
Household contact of immunocompromised individual
Vaccination details
Apply vaccine sticker if available
Pharmacy stamp
Name of
Date of
vaccine/
vaccination*
manufacturer*
Batch
Injection site*
Left upper arm
Number*
Right upper arm
Expiry
Route of
Intramuscular
administration*
Date*
Subcutaneous
Any adverse
effects*
Advice given
and any other
notes
Administered
Signature*
GPhC
number*
by*
(pharmacist name)
CONFIDENTIAL
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Parent category: Legal