Childhood Immunisation Form

Please read this statement carefully as you will be consenting to treatment.

I understand that I am opting for an elective treatment of vaccination

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization and that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, social distancing is recommended. This is not entirely possible with my proposed treatment; however, I am satisfied that safety measures are in place (see website for details) to minimise risk as much as possible, and patient contact will be kept to an absolute minimum in line with medical need.

I understand the Management and Clinical Staff are closely monitoring the COVID-19 situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19 (see website for full details). However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment, and I give my express permission to proceed.  

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. I understand that COVID-19 can cause additional health risks, some of which may not currently be known at this time, in addition to those risks associated with the treatment.

I have been given the option to defer my treatment to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment.

I confirm that I am not presenting with any of the following symptoms of COVOID-19 listed below:

• Fever
• Shortness of Breath
• Loss of Sense of Taste or Smell
• Dry Cough
• Runny Nose
• Sore Throat

By clicking this box I agree to the terms outlined above and I understand and consent to the administration of the advised medicine and allow the pharmacist to use the information I have supplied to keep as medical records (in line with GPDR). I also agree to pay a £10 consultation fee. If a treatment is administered after the consultation, this fee is deducted from the cost of the treatment. If no appointment is booked after assessment of the consultation form, this fee is non-refundable.


Personal Details

Name (required)

Date of Birth (required)

Contact Number Mobile

Emergency Telephone Number

Email (required)

GP surgery name (required)

Medical history

Treatment required: Childhood immunisation (tick one of the boxes below)
Chicken poxMeningitis BHepatitis B (non travel)HPV

Do you have any allergies?

Do you have any medical conditions?

Do you take regular medicines?

Are you pregnant or breastfeeding?

Have you had a severe reaction following an injection?

Have you ever fainted following an injection?

Do you have a bleeding or clotting disorder?

Are you taking any blood thinners?

Do you have any long-term chronic illness?

Do you have a disease/disorder that lowers your immune system (i.e. cancer /HIV)

Are you having treatment that lowers your immunity? (i.e. steroids, radiotherapy, Chemotherapy)

Have you had immunoglobulin or blood transfusion within the last 3 months?

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