McFadden Covid 19 Vaccination form

Your Name*

Your PPS Number*

Email*

Mobile Number*

I allow McFadden Pharmacy to contact me about this appointment.

Is Patient is minor? ( Aged 12-15 )*

Yes
No

Please enter parent's/guardian's name.*

Confirm parent's/guardian's phone number:*

Confirm parent's/guardian's email address:*

Patients Date of birth dd/mm/yyyy:*

Address incl Eircode:*

GP Name:*

Mother's birth surname (used by HSE to identify you):*

Gender (used by HSE to identify you):

Ethnicity (used by HSE to identify you):

Have you had anaphylaxis (serious systemic allergic reaction requiring medical intervention) following a previous dose of any vaccine or any of the constituents of the COVID-19 vaccines, including polyethylene glycol or polysorbate 80?

Yes
No

Have you been diagnosed with COVID-19 within the last 4 weeks?

Yes
No

Have you had another vaccine within the last 14 days?

Yes
No

Do you have a bleeding disorder or are you on anticoagulation therapy?

Yes
No

Are you pregnant

Yes
No

I (as a patient aged over 16 years or as a parent or guardian of the patient aged 15 years or under) have read and understand the vaccine information provided. including known side effects.

I understand that the COVID-19 vaccine is only recommended to be given between week 14 and week 36 of pregnancy.

I understand that I am giving consent for the administration of a COVID-19 vaccine including a 2nd dose.

Yes, I give consent to be vaccinated against COVID-19.

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