Author: emis2000
Last saved by: VAN DER STAM, Emma (BOURNBROOK VARSITY MEDICAL CENTRE)
Company: NHS South Birmingham

Bournbrook Varsity Medical Centre 
1A Alton Road, Selly Oak, Birmingham B29 7DU
Tel: 0121 472 0129  
Open Monday to Saturday
Dr C Allen, Dr M Swallow, Dr A Dungate, Dr S Clarke - Partners 
Dr M Philp, Dr A Nijjar, Dr H Cole, Dr S Ali, Dr J Tatlock, Dr N Ahmad, Dr N Grant, Dr E Al-Shammary - Associates

Trivalent Influenza Vaccine – Pre-assessment and Consent

Section A- Identity and Capacity

Patient Name:

Date of Birth:

Are you completing this for yourself?

Yes				No, I am a parent/ legal guardian

Name of person giving consent:

Relationship to patient:

Section B- Information

The flu vaccine helps protect against seasonal flu viruses and lowers the risk of serious complications or hospitalisation. 

Please read the link below for more information.
https://www.nhs.uk/vaccinations/flu-vaccine/

You may experience mild soreness, redness or swelling at the injection site or a mild headache/fever. These side effects are temporary and usually disappear within a few days. 

Serious allergic reactions are extremely rare but may involve facial swelling, breathing problems or collapse.

I have read and understood the information above:

Yes				No

Section C- Safety Screening

Have you received a flu vaccination yet in this flu season (1^st October 2026- 31^st March 2027)?

Yes			No
Have you ever had a severe allergic reaction to the flu vaccine, any component of the vaccine or any other injection?
Yes			No				Unsure

Do you have an egg allergy?
Yes			No

Are you currently acutely unwell with a fever or other infection? 

Yes			No 

Are you or could you be pregnant? 

Yes			No				

If answered YES to any questions a GP will review before the Influenza vaccine is administered.

Section D- Explicit Consent for PSD

I confirm that:

- I have read and understood the information provided.

- I will inform the Healthcare Assistant on the day of my vaccine appointment if any of this information has changed.

- I understand the vaccine will be given by a Healthcare Assistant under a Patient Specific Direction authorised by a GP or Independent Prescriber.

- I understand I can ask questions and withdraw consent at any time.

Do you give consent to receive the Cell-based Trivalent Influenza Vaccine (TIVc) at your upcoming appointment?

Yes					No

Print Name:					Signed:				Date: