If for any reason you cannot complete the online consent forms, please contact the local immunisation team. Parents/Guardians will be able to speak to an immunisation nurse who can take a verbal consent.
Student details
- Child's full name (first name and surname)
- Preferred Name
- Date of birth
- Sex at birth: Male or Female
- NHS number (if known)
- Name of parent/guardian
- Relationship to child
- Contact telephone number:
- Email address
- Home address and postcode
- GP name and Practice
- School
- Year group
- School class
- Have you read the information about the vaccine?
Health Questions
- Has your child been diagnosed with asthma?
- Does your child require oral steroid tablets for asthma?
- If yes and your child has taken steroid tablets in the past 2 weeks; please enter the name, dose and length of course
- Has your child been admitted to intensive care for their asthma?
- Has your child already had a flu vaccination in the last 5 Months? (if your child receives the vaccination at their GP's after you have 'returned this form, please let the Immunisation team know)
- Does your child have a disease or treatment that severely affects their immune system? (e.g. Leukaemia or taking immunosuppressant medication)
- Is anyone in your household currently having treatment that severely affects their immune system? (e.g.; they need to be kept in isolation)
- Has your child ever been admitted to intensive care due to an allergic reaction to eggs?
- Does your child have any allergies to Medication? ,
- Has your child ever had a reaction to a previous vaccinations?
- Does your child take regular aspirin? (salicylate therapy)
Student details
- Child's full name (first name and surname)
- Preferred Name
- Date of birth
- Sex at birth: Male or Female
- NHS number (if known)
- Ethnicity
- Home address and postcode
- GP name and Practice
- School
- Year group
- School class
Contact details
- Name of parent/guardian
- Relationship to child
- Contact telephone number
- Email address
- Have you read the information about the vaccine?
Health Questions
- Has your child had any previous reactions to any vaccination?
- Does your child take any regular medication?
- Does your child have a chronic or long term condition?
- Does your child have any severe allergies?
- Is your child currently seeing a doctor or receiving any treatment?
- Has your child had a dose of tetanus since having their pre-school booster?
Student details
- Child's full name (first name and surname)
- Preferred Name
- Date of birth
- Sex at birth: Male or Female
- NHS number (if known)
- Ethnicity
- Home address and postcode
- GP name and Practice
- School
- Year group
- School class
Contact details
- Name of parent/guardian
- Relationship to child
- Contact telephone number
- Email address
- Have you read the information about the vaccine?
Health questions
- Has your child had any previous reactions to any vaccinations?
- Does your child take any regular medication?
- Does your child have a chronic or long term condition?
- Does your child have any severe allergies?
- Is your child currently seeing a doctor or receiving any treatment?
Student details
- Child's full name (first name and surname)
- Preferred Name
- Date of birth
- Sex at birth: Male or Female
- NHS number (if known)
- Ethnicity
- Home address ad postcode
- GP name and Practice
- School
- Year group
- School class
Contact details
- Name of parent/guardian
- Relationship to child
- Contact telephone number
- E-mail address
- Have you read the information about the vaccine?
Medical history
- Has your child had a confirmed anaphylactic reaction to and previous dose of measles, mumps or rubella containing vaccine?
- Has your child had a severe local reaction to an immunisation?
- Does your child have any allergies to eggs, neomycin or gelatine?
- Does your child have any medical conditions that have affected their immune system?
- Does your child have any other vaccinations planned? i.e. for travel purposes?
- Is there anything else you think we should know about your child?