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Flu Vaccine Booking Form

I would like to book an appointment for:-(Required)

An intra-nasal vaccine for a child aged 2-17 years

An intramuscular vaccine for an adult aged 18 years or over

Name(Required)

First Middle Last

If completing this form for a child please add the details of the child to be vaccinated (other than mobile phone number and email if you wish use your own)

Gender(Required)

Male

Female

Are you pregnant?(Required)

Yes

Enter Email Confirm Email

If you have no email please click next to proceed to next question

Phone(Required)

Mother's Birth Surname

Date of Birth(Required)

DD slash MM slash YYYY

Address(Required)

Street or town Town (if none add none to box) 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 October 2024 to end of February 2025

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.

Are you at risk of lymphoedema in both arms?

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?(Required)

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

For adults: Influvac Tetra (manufacturer Mylan) suspension for injection in pre-filled syringe (influenza vaccine, surface antigen, inactivated). This vaccine may contain traces of eggs (such as ovalbumin, chicken proteins), formaldehyde, cetyltrimethylammonium bromide, polysorbate 80 or gentamicin, which are used during the manufacturing process. List of excipients: Potassium chloride, Potassium dihydrogen phosphate, Disodium phosphate dihydrate, Sodium chloride, Calcium chloride dihydrate, Magnesium chloride hexahydrate, Water for injections Quadrivalent Influenza Vaccine (split virion, inactivated) (Sanofi) This 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 For children: Child’s Fluenz Tetra nasal spray suspension Influenza vaccine (live attenuated, nasal) (AstraZeneca) Gelatin, gentamicin, potassium dihydrogen phosphate. sucrose, arginine hydrochloride, monosodium glutamate monohydrate, dipotassium phosphate, water for injections

The following question only needs to be filled out for those requesting the intra-nasal vaccine for children aged 2-17 years inclusive. Please tick any applicable boxes or leave boxes unticked if none apply. Does the 2-17 year old?

Live with anyone who is severely immunocompromised?

Take aspirin/salicylate therapy?

Take regular steroids or require intensive care treatment for asthma?

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

I am aged 60 years or older

I am a child aged 2 to 17 years

I am pregnant

I am a healthcare worker

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 household contact of a person at increased medical risk

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

I have a condition that compromises my respiratory function (e.g. spinal cord injury, seizure disorder, or other neuromuscular disorder)

I am a carer of a person at increased medical risk (medical conditions listed above)

I am in regular contact with pigs, poultry or waterfowl

None of the above applies I will pay for my vaccine

If none are applicable, select the last option ‘None of the above applies’ You will be charged €35 for a private vaccine

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

Yes

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

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)

Comments

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