Nhs Community Pharmacy Seasonal Influenza Vaccination Advanced Service - Record & Consent Form Page 2

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To be completed by pharmacy staff
Any allergies
Eligible patient group*
65 years or over
Chronic respiratory disease
Chronic heart disease
Chronic kidney disease
Chronic liver disease
Chronic neurological disease
Diabetes
Immunosuppression
Asplenia / splenic
Pregnant woman
dysfunction
Person in long-stay
Carer
residential care home or
care facility
Morbid obesity (BMI ≥ 40)
Household contact of
immunocompromised
individual
Vaccination details
Apply vaccine sticker if available
Name of
Date of
Pharmacy stamp
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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