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COVID-19 Spring 2025 Consent Form

COVID-19 Spring 2025 Consent Form

Patient Information

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I am eligible because

Eligibility On Grounds of Weakened Immune System

We strive to make your vaccination appointment as straightforward and efficient as possible.

As part of our commitment to public health and in accordance with our contractual obligations, we are dedicated to providing a safe and effective COVID-19 vaccination campaign. This means we can only vaccinate individuals who meet the eligibility criteria established for this spring.

Whilst most recipients of the NHS vaccination invitation letter will be eligible, there may be instances of incorrect invitations. Hence, a clinical assessment is required prior to vaccination. Please bring any relevant documents to assist with your assessment.

Below are the eligibility criteria outlined by our commissioners, select the one that most applies to you

Select other, if none listed applies to you, in which case we encourage you to call us on
01932 842642 to discuss your situation before your appointment. This will help prevent any unnecessary trips in case you are not eligible for vaccination at this time.

Thank you for your understanding and cooperation. We look forward to assisting you.

Individuals with primary or acquired immunodeficiency states at the time of last vaccination due to conditions including:

Vaccine Information

COVID-19 Vaccine (Spikevax JN.1):
The COVID-19 vaccine helps protect against severe illness, hospitalization, and death caused by COVID-19. Common side effects may include pain at the injection site, fatigue, headache, muscle pain, chills, fever, and nausea. Most side effects are mild and resolve within a few days.

Spikevax (JN.1) Patient Information Leaflet: https://www.medicines.org.uk/emc/files/pil.15914.pdf

Consent

I acknowledge that I have received information regarding the COVID-19 and flu vaccines, including their benefits and potential side effects.
Please enter your full name.

Medical History

Please answer the following questions to assist in your vaccination process.
Have you ever had an anaphylactic reaction to any vaccine?
Are you currently taking any blood thinners or do you have a bleeding/clotting disorder?
Do you have a history of capillary leak syndrome?
Are you currently unwell with an acute fever?
The presence of minor infections is not a reason to postpone vaccination.

Emergency Contact Information

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