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NHS Prescriptions
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Travel Clinic
Shingles Vaccine
Contact Us
Login
NHS Prescriptions
Vaccination details
Vaccine
*
Avaxim (Sanofi Pasteur)
Dukoral (Valneva UK)
Engerix-B (GSK)
Gardasil 9 (MSD)
Havrix Monodose (GSK)
Havrix Monodose Junior (GSK)
Hydroxocobalamin 1mg in 1ml
Ixiaro (Valneva UK)
Rabipur (Valneva UK)
Revaxis (Sanofi Pasteur)
Shingrix (GSK)
TYPHIM Vi (Sanofi Pasteur)
Vaqta Adult (MSD)
Vaqta Paediatric (MSD)
Varivax (MS&D)
Viatim (Sanofi Pasteur)
Zostavax (MSD)
Vaccine - Other
Batch Number
*
Expiry Date
*
DD
MM
YYYY
Administration Details
Date of Administration
*
Date Format: DD slash MM slash YYYY
Injection Site
*
Left Upper Arm
Right Upper Arm
Left Thigh
Right Thigh
Oral
Injection Route
*
Intramuscular
Subcutaneous
Oral
Any Adverse Effects
N/A
Advice given and any other notes
N/A
Administered by
*
Zaydoun Abbas
Shama Mahammed
Patient’s Details
Name
*
First
Last
DOB
*
Date Format: DD slash MM slash YYYY
NHS
Phone
*
Email
*
Address
*
Street Address
City
Post Code
GP Surgery
*
Please select your GP surgery
Dr Johnson And Partners
Richmond Medical Group - Sheen
Chartfield Surgery
Danebury Avenue Surgery
Essex House
Glebe Road
Kew Medical Practice
Mayfield Surgery
Paradise Road
Parkshot Medical Practice
Putneymead Group Medical Practice
Richmond Medical Group - Kew
Seymour House - Richmond
Seymour House - Ham
The Alton Practice
The Heathbridge Practice
The Roehampton Surgery
The Vineyard Surgery
Other
Please type the name of your GP surgery
Patient’s Next of Kin
Name
First
Last
Phone
Relationship
Screening Questions
Are you currently sick with a fever or any type of infection?
*
Yes
No
Do you have a severe (life-threatening) allergy to eggs or any component (or part) of this injectable, including gelatine, neomycin, sucrose, sodium chloride, L-glutamate, sodium phosphate, potassium phosphate, potassium chloride, streptomycin or polymyxin B?
*
Yes
No
Have you ever had a severe (life-threatening) allergic reaction to a previous dose of any injectable?
*
Yes
No
Have you received any vaccinations or injectable medication in the past 4 weeks?
*
Yes
No
Do you have any existing liver, kidney or heart conditions?
*
Yes
No
For women: Are you breastfeeding, pregnant or is there a chance you could become pregnant during the next month?
*
Yes
No
No Applicable
Consent
Consent
*
I agree to be given the injection by a trained pharmacist
We will send your name, address and information about your treatment to your GP practice so they can update your health record.
Comments
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Next Appointment - Time
:
HH
MM
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PM
Name
This field is for validation purposes and should be left unchanged.
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