Flu Vaccination Registration Form Flu Vaccination Registration Form "*" indicates required fields Step 1 of 4 25% Confirmation*Flu vaccination is free to everyone in the at-risk groups listed below. You have selected a private HSE vaccine. If you are in any of the at-risk groups below please book an appointment for a Free HSE Flu Vaccine instead. - All those aged 65 years and older - All children aged 2 - 17 inclusive - All pregnant women (at any stage of pregnancy) - Chronic respiratory disease including cystic fibrosis, moderate or severe asthma, COPD - Chronic heart disease - Chronic renal (kidney) disease - Diabetes liver disease - Chronic neurological disease including multiple sclerosis - Hereditary and degenerative disorders of the central nervous system etc. - Cancer patients - Residents of nursing homes and other long stay facilities - Children with conditions that compromise respiratory function e.g. spinal cord injury, seizure or other neuromuscular disorder - Morbid obesity i.e. Body Mass index over 40 - Those who are immunosuppressed due to disease or treatment including those with missing or non-functioning - Healthcare workers - Carers of persons with increased medical risk - Household contacts of persons with increased medical risk - People who have close, regular contact with pigs, poultry or water fowl - Down Syndrome - Children on long-term aspirin therapy This Flu Vaccine for Winter 2022/2023 contains protection against the following strains of influenza as recommended by the WHO: A/Victoria/2570/2019 (H1N1)pdm09 - like virus A/Cambodia/e0826360/2020 (H3N2) - like virus B/Washington/02/2019 - like virus B/Phuket/3073/2013 - like virus Vaccines also contain residues and other ingredients, and it is important to tell us if you have any known allergies or have had a severe reaction to a previous vaccine. Advice to patient: - Do not attend if you feel unwell, have a fever, or any covid symptoms, or if you are a close contact of someone with Covid. - Wear a face mask; - Wear loose fitting clothing to allow an injection in the upper arm; - You will be asked to wait in the pharmacy for 5 mins after vaccination, and remain in close proximity for a further 10 minutes. - Before vaccination you will have to confirm you have no symptoms of COVID and had no close contact with anyone with COVID in the past 14 days. I understand and consent to the above Choose Your Preferred Location:*Blessington Main StreetPrimary Care BlessingtonLower Main Street BlessingtonBaltinglass PharmacyNewbridge PharmacyPortarlington PharmacyWeirs Pharmacy MullingarGlenagearyAppointment Type*Flu Vaccine Private - €30Flu Vaccine Over 65 - FreeFlu Vaccine 2 - 17 (Nasal Spray) - FreeFlu Vaccine 18 - 64 with underlying conditions - FreeDetails Flu Vaccine Private - €30 Book this service if you are aged 18-64 and do not have any risk factors. Flu Vaccine Over 65 - Free Book this service for your free flu vaccine if you are 65 or older. Flu Vaccine ages 2 to 17 years (Nasal Spray) Book this service if you require your child to get the Nasal Spray Flu Vaccine ages 18 - 64 years with additional risk factors You will need to specify your risk factors as part of the booking process. (The risk factors are outlined in the next step) Please tick all of the risk factors below which apply to you: (NOTE: To be eligible for a free flu vaccine and to book this appointment you must have one or more of the risk factors below) Pregnant Chronic Respiratory Disease e.g. Asthma COPD Chronic Heart Disease Chronic Kidney Disease Chronic Liver Disease Diabetes Immunosuppressed Morbidly Obese (BMI over 40) Household contact of person with increased risk Healthcare worker- Medical/Dental Healthcare Worker- Nursing Healthcare worker- Health and Social Care staff Healthcare worker - Management/Administration Health Care Worker- General Support Staff Healthcare worker- Other Down syndrome Resident of a nursing home or other long stay facility Chronic Neurological disease e.g. MS Epilepsy Parkinsons Disease Carer (Providing significant level of care to an at risk individual) Name* First Last Phone* Date of Birth* DD slash MM slash YYYY PPS Number, Medical Card, Doctor Visit Card or DPS Number:* Gender:*MaleFemaleOtherAddress:* GP Name & Address (If you have a GP): Have you ever had a serious allergic reaction to a vaccine, food or drug? (If yes, please describe below as you may need to get your vaccine in a hospital setting):*YesNoAllergic Reaction Experienced:If you answered Yes to the previous question, please describe the type of allergic reaction you experienced and when you experienced it. I consent to the recording and keeping of data pertaining to this service:*YesNo
