Vaccinations - Q Health Pharmacy

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Flu Vaccination Form

PLEASE ONLY REGISTER ONCE

Please choice which vaccination you would like to register for *

Adult Flu VaccinationChild Flu Vaccination

By registering my child for the vaccine I give my implicit consent for them to receive it

Link to Nasal Flu Form

https://www.hse.ie/eng/health/immunisation/hcpinfo/fluinfo/englaivconsentformall.pdf

PPS NO.: *

School

First Name *

Last Name *

Email Address *

Phone *

Street Address *

City *

County *

Eircode *

Date Of Birth *

Do you agree to Q Health contacting you via Telephone or Email?

YesNo

Has your child ever suffered from previous anaphylactic reactions *

YesNo

Are you taking any medications? *

Yes (list below)No

If you answered Yes, Please list your medication

Do you suffer from any of the following

DiabetesBlood PressureHeart Disease or AnginaArthritisEye ConditionsAsthmaCOPD

Any Allergies?

Do you regular take any OTC medicines?

I have read and understand the vaccine information including the known side effects

I understand that I am giving consent for the administration of Nasal Flu vaccine

I confirm that I am authorised to give consent on behalf of the above named child

YES, I consent to the above named child to receive the flu vaccine.

GDPR *I consent to having this website store my submitted information so that my enquiry can be responded to. I agree with the privacy policy

Signed *

PLEASE ONLY REGISTER ONCE

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About us

Q Health Pharmacy (formally known as Quirkes Pharmacy) has been in existence on Kilkenny Street, Castlecomer since 1995. Feb 2019 saw it move up to the street to its present location just at the corner of the square in what was used to be known locally as Hahessy’s drapery.

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