ASFA Flu Vaccine Consent Form "*" indicates required fields Student's Name* First Last Address* Street Address Address Line 2 City ZIP / Postal Code NHS Number (if known) Student's Date of Birth* MM slash DD slash YYYY Year Group*Year 7Year 8Year 9Year 10Year 11Email Daytime contact telephone number for parent/guardian/carer:* GP Name* GP Address* Street Address Address Line 2 ZIP / Postal Code Has your child required oral steroids in the last 2 weeks to manage their asthma? If YES - Please inform the Immunisation team if your child’s asthma deteriorates and you have had to increase their medication after you have returned this form, please call: 0151 295 3833* Yes No If YES please give details Does your child have a disease or treatment that severely affects their immune system? (e.g. treatment for Leukaemia)* Yes No If YES please give details Is anyone in your family currently having treatment that severely affects their immune system? (e.g. they need to be kept in isolation)* Yes No If YES please give details Does your child have a severe egg allergy? (needing intensive care) Yes No If YES please give details Does your child take salicylate medication (Aspirin)? Yes No If YES please give details If you answered YES to any of the above, please make sure you give details in the box provided. The Immunisation team may contact you for further information. NB. The nasal flu vaccine contains a highly processed form of gelatine derived from pigs (porcine gelatine). It is offered because it is more effective in the programme than an injected vaccine. This is because it is considered better at reducing the spread of flu to others and is easier to administer. Some people may not accept the use of porcine gelatine in medical products. You should discuss your options with the Immunisation team.CONSENT - you MUST choose YES or NO from the dropdown below*YES, I give consent for my child to be immunised with the nasal flu vaccine.NO, I do not give consent for my child to be immunised with the nasal flu vaccineYour Name* First Last Today's Date* MM slash DD slash YYYY
