Flu and Covid Booster Booking Form

Covid and Flu Vaccination Booking Form

Name(Required)

First if none state none Last

Gender(Required)

Male

Female

Are you pregnant?(Required)

Yes

Email(Required)

Enter Email Confirm Email

Phone(Required)

Mother's Birth Surname(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Address(Required)

Street Address Town (if none add none) County Eircode

Please enter the PPSN of the person to be vaccinated(Required)

A PPS Number is always 7 numbers followed by either one or two letters. If you do not have one enter xxxxxxxxx (9 x's)

Have you had the flu vaccine in previous years?(Required)

Yes

Have you had a flu vaccination already this season?(Required)

Yes

In general, most people only require one flu vaccination per influenza season, which usually runs from September 2022 to end of April 2023

Are you recommended to get a 2nd flu vaccination in this season?(Required)

Yes

Cancer patients who receive the vaccine while on chemotherapy and who complete their treatment in the same season are recommended to get a second flu vaccine at least 4 weeks after their first

Have you ever had a serious allergic reaction to any previous flu vaccine or injectable therapy?(Required)

Yes

If you had an allergic reaction to a previous flu vaccine you will be at a higher risk of having an allergic reaction again. It is recommended that this is given in a different healthcare setting, such as doctor's surgery or hospital.

Do you have an allergy to eggs?(Required)

Yes

If you have an allergy to eggs then you should not receive the vaccine in the pharmacy. Ask our pharmacist for more information.

Do you have a severe allergy to latex?(Required)

Yes

Are you at risk of lymphoedema in both arms?If you are at risk of lymphoedema in BOTH arms the vaccination service in the pharmacy will not be suitable for you, contact our pharmacist for further advice.(Required)

Yes

If you are at risk of lymphoedema in BOTH arms the vaccination service in the pharmacy will not be suitable for you, contact our pharmacist for further advice.

Do you suffer from any bleeding disorder or are you taking anticoagulant medication such as warfarin/Eliquis/ Pradaxa/Lixiana or Xarelto?(Required)

Yes

Have you had a haematopoeitic stem cell or solid organ transplant?(Required)

Yes

Are you taking combination checkpoint inhibitors (e.g. ipilimumab plus nivolumab)?(Required)

Yes

If taking combination checkpoint inhibitors you should not receive influenza vaccine because of a possible risk of immune associated adverse reactions.

Do you have very low levels of a type of white blood cell, neutrophils?

Yes

If you have very low levels of neutrophils then you should not receive a flu vaccination. Ask our pharmacist for more information.

Do you have an allergy to any of the following ingredients which are contained in the flu vaccine? If you do you should not receive your vaccine in the pharmacy please ask our pharmacist for further advice(Required)

Yes

QUADRIVALENT INFLUENZA VACCINE ADULT 18 YEARS+ (split virion, inactivated) (Sanofi) The vaccine may contain traces of eggs, such as ovalbumin, chicken proteins and of neomycin, formaldehyde and octoxinol-9, which are used during the manufacturing process. List of excipients: Buffer Solution: Sodium chloride, Potassium chloride, Disodium phosphate dihydrate, Potassium dihydrogen phosphate

Select if one of the following risk groups recommended by the HSE to get a flu applies to you:(Required)

I am aged 65 years or older

I am a healthcare worker

I am pregnant

I have chronic heart disease, including acute coronary syndrome

I have chronic liver disease

I have chronic kidney failure

I have chronic respiratory disease (including chronic obstructive pulmonary disease (COPD), cystic fibrosis, moderate or severe asthma, or bronchopulmonary dysplasia)

I have chronic neurological disease (including multiple sclerosis, hereditary and degenerative disorders of the central nervous system)

I have diabetes

I have Down syndrome

I have haemoglobinopathies

I have morbid obesity, which means a body mass index (BMI) over 40

I have immunosuppression due to disease or treatment (including asplenia or hyposplenism, and cancer patients)

I am a carer of a person at increased medical risk

I am a household contact of a person at increased medical risk

I am living in a nursing home or other long-term care facility

I am in regular contact with pigs, poultry or waterfowl

None of the above applies

If none are applicable, select the last option ‘None of the above applies’ You will be charged €30 for a private vaccine

Have you ever had a serious allergic reaction (anaphylaxis) that needed medical treatment: after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine, OR to any of the vaccine ingredients, including polyethylene glycol known as PEG OR to any other previous vaccine (including the flu vaccine)?(Required)

Yes

Do you have an allergy to any of the following ingredients contained in the Pfizer Comirnaty vaccine?(Required)

Yes

(4-hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate) (ALC-0315), 2-[(polyethylene glycol)-2000]-N,N-ditetradecylacetamide (ALC-0159), 1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC), cholesterol, trometamol, trometamol hydrochloride, sucrose, water for injections

Have you ever had a serious allergic reaction (anaphylaxis): after taking multiple different medications, with no reason known for the reaction. This may mean you are allergic to polyethylene glycol (PEG) OR after having a vaccine or a medicine that contains polyethylene glycol (PEG), OR unexplained reasons? This may mean you are allergic to polyethylene glycol (PEG)(Required)

Yes

Do you have an allergy to Trometamol (a contrast dye use in MRI radiological studies) and contained in Pfizer vaccines?(Required)

Yes

Have you had pericarditis (inflammation of the lining around the heart) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine?(Required)

Yes

Move Have you had myocarditis (inflammation of the heart muscle) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID19 vaccine?(Required)

Yes

Have you ever had: Mastocytosis (rare condition caused by an excess number of mast cells gathering in the body's tissues) OR idiopathic anaphylaxis. This is a condition diagnosed by an immunologist. OR a serious allergic reaction (anaphylaxis) due to food, medication or venom from an insect or animal?(Required)

Yes

Do you have a history of capillary leak syndrome?(Required)

Yes

Which COVID-19 vaccine dose do you wish to book an apppointment for?(Required)

Booster 1

Booster 2

Booster 3

To determine which booster you are eligible for please consult HSE guidelines by clicking on the link below (please note that the "primary course" of vaccination is two Pfizer, Moderna or Astra Zeneca vaccines or one Janssen vaccine each vaccine after these are called boosters)

HSE Booster Vaccines Information

Are you booking a booster due to being in a very high risk or high risk group (as your age group is currently not eligible for vaccination)? Please note we will ask you when you present for your vaccine what your reason for vaccination is and may refuse to vaccinate you if you are outside the current age HSE age group and do not have a valid risk condition(Required)

Yes

For Booster 3 please click on the Booster 3 eligibility outside being over 65 or older list For Booster 2 please click on the Booster 2 eligibility outside being over 50 or older list

Booster 3 eligibility outside being over 65 or older list

Booster 2 eligibility outside being over 50 or older list

Do you have a regular G.P?(Required)

Yes

Please give the name of you G.P. and the practice address

if none state none

What is your ethnicity?(Required)

Prefer not say

Irish

Irish Traveller

Any other white background

African

Any other black background

Chinese

Any other Asian background

Roma

Other (incl. mixed background)

What is your nationality?(Required)

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