NHS Community Pharmacy Seasonal Influenza Vaccination
Advanced Service - Record & Consent Form
* indicates sections that must be completed
Date of birth*
Patient’s emergency contact
Relationship to patient
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
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) and the NHS BSA for the purposes of checking payments
to the pharmacy and to allow them to make sure the service is
being provided properly.