Children’s Flu Vaccination

Influenza Virus

The children’s nasal spray flu vaccine is safe and effective. It’s offered every year to children to help protect them against flu.

Flu is caused by the influenza virus. It can be a very unpleasant illness for children. It can also lead to serious problems, such as bronchitis and pneumonia.

Children can catch and spread flu easily. Vaccinating them also protects others who are vulnerable to flu, such as babies and older people.

For further information click https://www.nhs.uk/conditions/vaccinations/child-flu-vaccine/

Children's Flu Vaccination Form

Phone
This field is for validation purposes and should be left unchanged.
Before attending the surgery with your child for vaccination, please provide the following details and answer the general health questions below.
--- Child Details ---
Child's Name(Required)
First Last
Child's Date of Birth(Required)
Day
Month
Year
--- Parent Details ---
Parent's Name(Required)
First Last
Address(Required)
House Number/Street Postcode
Parent's Contact Phone Number(Required)
Please confirm that your child:
Is well today?(Required)
Has had no allergic reaction to any previous vaccines including the nasal flu vaccine?(Required)
Has never had a serious allergic reaction to anything that has resulted in admission to intensive care?(Required)
Is not allergic to gelatine or gentamycin (an antibiotic)?(Required)
Has never been admitted to intensive care with severe asthma and has not taken steroid tablets to control asthma in the last 14 days?(Required)
Has not been wheezing in the past 3 days (if asthmatic)?(Required)
Is not taking aspirin?(Required)
Does not suffer with any medical conditions that affect their immune system working normally?(Required)
Is not in close regular contact with a household member who has a weakened immune system (for example, someone undergoing cancer treatment or someone who has had an organ transplant?(Required)
If any of these apply, please provide details below:
Date Form Completed(Required)
Day
Month
Year
What happens to my information?
Personal and medical information about patients registered at Peverell Park Surgery is primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you (please refer to our Privacy Policy), for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.
Consent(Required)
- I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Peverell Park Surgery & University Medical Centre

Children’s Flu Vaccination

Children's Flu Vaccination Form

--- Child Details ---

--- Parent Details ---

Please confirm that your child:

What happens to my information?

Check out our CQC report

Peverell Park Surgery & University Medical Centre

Children’s Flu Vaccination

Children's Flu Vaccination Form

--- Child Details ---

--- Parent Details ---

Please confirm that your child:

What happens to my information?

Check out our CQC report

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