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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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Spirometry / Lung Testing
Executive Health Screening
Sexual Health Clinic / STI Testing
24 Hour Blood Pressure Monitoring
Flu Vaccine Clinic
Heart Testing
Phlebotomy / Blood Tests
Men’s Health
Executive Health Screening
Sexual Health Clinic / STI Testing
Other Services
Eye sight testing for driving
Audiometry
Suturing
Insurance Medicals
GP Care for under 6’s
GP care for over 70’s
Ear Syringing
Policies
About
Contact
Links
Patient Forms
Repeat Prescriptions
Request Appointment
Child Flu Vaccination Consent Form
COVID-19 Testing
Home
Services
Women’s Health
Family Planning/Contraception
Ante-natal Care
Implanon Insertion/Removal
Cervical Screening – Smears
Sexual Health Clinic / STI Testing
Executive Health Screening
Occupational Services
Pre-employment Medicals
Fitness to Work Assessments
Workplace Assessments
Absence Management
Health Promotion & Surveillance
Specialist Clinics
Childhood vaccines
Diabetic linic
Asthma Clinic
Spirometry / Lung Testing
Executive Health Screening
Sexual Health Clinic / STI Testing
24 Hour Blood Pressure Monitoring
Flu Vaccine Clinic
Heart Testing
Phlebotomy / Blood Tests
Men’s Health
Executive Health Screening
Sexual Health Clinic / STI Testing
Other Services
Eye sight testing for driving
Audiometry
Suturing
Insurance Medicals
GP Care for under 6’s
GP care for over 70’s
Ear Syringing
Policies
About
Contact
Links
Patient Forms
Repeat Prescriptions
Request Appointment
Child Flu Vaccination Consent Form
COVID-19 Testing
Child Flu Vaccination Consent Form
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Patient Forms
Child Flu Vaccination Consent Form
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*
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Last
Email
*
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*
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Child's Name
*
First
Last
Date of Birth
*
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*
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*
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*
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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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