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Flu form

Home › Flu form

Flu immunisation form

This vaccination programme is in place to help protect your children in primary
school against flu. Flu can be an unpleasant illness and sometimes causes serious
complications. Vaccinating your child will also help protect more vulnerable friends
and family by preventing the spread of the flu.

You can find further information on the Flu spray by visiting the Government website

Flu immunisation e-consent form

Step 1 of 2

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Parent/Guardian/Carer to complete

Please complete all fields as best as you can
Do you have legal responsibility for the child*
- Yes
- No
If you do not have legal responsibility for the child you cannot give consent for the child to receive the vaccination.
You cannot continue with consent for the child to have a flu vaccination if you do not have legal responsibility for the child.
Student details
Student details*
First name Surname
Gender*
Date of birth*

Day
Month
Year
NHS number (if known):
Ethnicity
Main language
GP surgery
School*
Year group*
Home address*
Street Address Address Line 2 Town County Post Code
Contact telephone number*

Has your child ever had a confirmed anaphylactic reaction to a previous dose of a live Influenza vaccine?*
- Yes
- No
- Not applicable / child has not previously received a flu vaccination
Is your child currently having treatment that severely affects their immune system and has been advised to avoid live vaccinations? (eg.they are receiving treatment for Leukaemia)*
- Yes
- No
Does your child have close, unavoidable contact with a family member who is severely immunocompromised (eg. receiving a bone marrow transplant)?
- Yes
- No
Has your child ever been admitted to hospital for intensive care due to an anaphylactic reaction to eggs?*
- Yes
- No
Is your child receiving salicylate therapy (e.g. aspirin)?*
- Yes
- No
Has your child been diagnosed with asthma?*
- Yes
- No
Has your child ever received treatment in intensive care due to the severity of their asthma?*
- Yes
- No
Does your child require regular oral steroids for the maintenance of their asthma?*
- Yes
- No
Please let the immunisation team know if your child has had to increase his or her asthma medication and on the day of vaccination, please let the team know if your child has been wheezy or had a bad asthma attack in the past three days. Call us on 01226 438829
Consent for immunisation
Please read
1. The nasal flu vaccine contains products derived from pigs (porcine gelatine). Please contact a member of the vaccination team on 01226 438829 to discuss an alternative flu vaccine. More information for parents is available from www.nhs.uk/child-flu
2. Please let the vaccination team know if your child has had to increase his or her asthma medication after you have completed this form
3. On the day of vaccination, please let the immunisation team know if your child has been wheezy in the past 3 days
4. IF AFTER YOU RETURN THIS FORM YOUR CHILD HAS THEIR FLU VACCINATION ELSEWHERE IT IS YOUR RESPONSIBILITY TO MAKE THE VACCINATION TEAM AWARE TO AVOID DUPLICATION.
5. If your child misses or refuses their flu spray in school or consent is received after the school visit, you will be invited to bring them to one of our community clinics.
I confirm that I have read the above information and*
- YES, I consent for my child to receive the flu immunisation
- NO, I DO NOT consent for my child to receive the flu immunisation
What is the main reason that you do not wish to for your child flu vaccination?
Are you happy for information on this form to be viewed by school staff?*
- Yes
- No
Your Name*
What is your relationship to the child?*
Date of consent*
Please choose today's date

Day
Month
Year
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Page last updated on: 28^th July 2021

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