To be completed by pharmacy staff Any allergies NHS Eligible patient Aged over 65 Chronic respiratory disease Chronic heart disease Chronic kidney disease Chronic liver disease Chronic neurological disease Diabetes Immunosuppression Splenic dysfunction Pregnant woman Person in long-stay Carer / Social Care Work / Hospice residential or home Worker Household contact of Morbid Obesity (BMI 40) ≥ immunocompromised individual Vaccination details Name of Date of Pharmacy stamp Apply vaccine sticker if available vaccine/ vaccination* manufacturer* Batch Injection site* Left upper arm Number* Right upper arm Expiry Route of Intramuscular Date* Subcutaneous Any adverse effects* Advice and any other notes Administered Signature* GPhC number* by* (pharmacist name)
To be completed by pharmacy staff Any allergies NHS Eligible patient Aged over 65 Chronic respiratory disease Chronic heart disease Chronic kidney disease Chronic liver disease Chronic neurological disease Diabetes Immunosuppression Splenic dysfunction Pregnant woman Person in long-stay residential or home Carer / Social Care Work / Hospice Worker Household contact of immunocompromised individual Morbid Obesity (BMI ≥ 40) Vaccination details Name of vaccine/ manufacturer* Apply vaccine sticker if available Date of vaccination* Pharmacy stamp Batch Number* Injection site* Left upper arm Right upper arm Expiry Date* Route of Intramuscular Subcutaneous Any adverse effects* Advice and any other notes Administered by* (pharmacist name) Signature* GPhC number*
council_2018-19_-_flu-vaccination-record-and-consent-form.docx