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The Faythe Medical Centre

Patient Centered Healthcare

053 91 42355 The Faythe Medical Centre, 178 The Faythe, Wexford, Y35 RK61

The Faythe Medical Centre
178 The Faythe, Wexford,
Y35 RK61

053 91 42355

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COVID-19 Testing

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COVID-19 Testing

Child Flu Vaccination Consent Form

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Child Flu Vaccination Consent Form

Parent/ Guardian Details
Parent/ Guardian's Name*
First Last
Email*
Parent/ Guardian Mobile:*
Child Details
Child's Name*
First Last
Date of Birth*
Gender*
- Girl
- Boy
GMS/ PPS Number:*
Home Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
Asthma
Has your child ever been diagnosed with Asthma?
- Yes*
- No
If Yes, Has your child taken steroid tablets because of their asthma within the past two weeks?
- Yes*
- No
Has your child ever been admitted to intensive care because of their asthma?
- Yes*
- No
Has your child had to increase their asthma medication in the last 3 days?
- Yes*
- No
*If you answered Yes to any of the above, please give details :
General Questions
Has your child already had a flu vaccination since September 2020?
- Yes*
- No
Has your child been treated with antiviral Medication within the previous 48hours?
- Yes*
- No
Does your child have a disease or treatment that severely affects their immune system? (e.g. treatment for leukaemia, or very low white cell count, or immunosuppressant therapy etc)
- Yes*
- No
Is anyone in your family currently or living with you having treatment that severely affects their immune system? (e.g. they need to be kept in isolation)
- Yes*
- No
Does your child have a severe egg allergy? (requiring intensive care unit admission).
- Yes*
- No
Has your child ever had a severe allergic reaction to a previous dose of flu vaccine or other vaccine?
- Yes*
- No
Is your child receiving salicylate therapy? (i.e. aspirin)
- Yes*
- No
Is there any possibility that your child could be pregnant?
- Yes*
- No
*If you answered Yes to any of the above, please give details:
Consent for Immunisation
I am unable to attend on the day with my child but I have designated the following person to accompany my child and be responsible for them on the day at the clinic and following the vaccination: (name of person)
First Last
I confirm that I have read and understand the content of the HSE information leaflet on the Flu Vaccine for Children aged 2-12.*
- I consent for my child to receive the flu immunisation.

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Contact / Location

Address: The Faythe Medical Centre,
178 The Faythe, Wexford, Y35 RK61
Phone: 053 91 42355
Email: info@tfmc.ie

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