Injection Consent Form – Spatetree Pharmacy

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Travel Clinic
Shingles Vaccine
Contact Us
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NHS Prescriptions

Travel Clinic
Shingles Vaccine
Contact Us
Login
NHS Prescriptions

Vaccination details
Vaccine*
Vaccine - Other
Batch Number*
Expiry Date*

DD
MM
YYYY
Administration Details
Date of Administration*
Date Format: DD slash MM slash YYYY
Injection Site*
Injection Route*
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
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
Next Appointment
Next Appointment - Date
Next Appointment - Time

: HH

MM
Name
This field is for validation purposes and should be left unchanged.