ASFA Flu Vaccine Consent Form

"*" indicates required fields

Student's Name*
MM slash DD slash YYYY
GP Address*
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*
Does your child have a disease or treatment that severely affects their immune system? (e.g. treatment for Leukaemia)*
Is anyone in your family currently having treatment that severely affects their immune system? (e.g. they need to be kept in isolation)*
Does your child have a severe egg allergy? (needing intensive care)
Does your child take salicylate medication (Aspirin)?

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.

Your Name*
MM slash DD slash YYYY