Hayfever Consultation Form

Before you book your consultation please read the following: 

You cannot have the injection if:

  • You have had an allergic reaction to Kenalog or any similar steroids 
  • You currently have an infection 
  • You have osteoporosis 
  • You have or previously had psychosis in the past 
  • You have glaucoma 
  • You have diabetes, epilepsy, high blood pressure or heart problems 
  • You are pregnant or breastfeeding (Or planning a pregnancy in the next 6 months)
  • You have any planed surgery including dental work. 
  • You are under 12 years of age. 

 

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

Yes

Personal Details

Name (required)

Date of Birth (required)

Contact Number Mobile

Emergency Telephone Number

Email (required)

GP surgery name (required)

Medial quesitions

Do you have any allergies?
YesNo

Are you currently receiving medial attention or have any long term chronic illness including mental health illness?
YesNo

Are you taking any medication (include your over the counter medicines and any hay fever related medicines)
YesNo

Have you had a severe reaction following an injection?
YesNo

Do you have a bleeding or clotting disorder?
YesNo

Are you taking any blood thinners?
YesNo

Have you had chicken pox?
YesNo

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

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

Kenalog injection is a steroid injection of triamcinolone acetonide 40mg/ml. Have you had any previous treatment with this medication before? If you state ‘yes’ please state when and what dose.
YesNo

Consent: Yes

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.

I agree that it is my responsibility to notify my GP of the injections/treatment I have had administered

Please note your details are not shared with anyone or used for any marketing purposes. Your information is stored on our secure database system for the purpose of our requirements to carry out our service. Please see our privacy notice for any further information.

This form is an advanced consent to treatment – to minimise time spent in the pharmacy as we cannot maintain a 2 meters distance safely for the duration of your visit. However, we will perform a consultation where you will have the opportunity to ask questions and the pharmacist will cover all the potential risk of treatment.

Information provided by:
I have provided this information about myselfI have provided this information on behalf or someone else
Please provide your full name if providing this information for someone else:

Input this code: captcha