Jai Medical Centre

Edgware Surgery, 114 Edgwarebury Lane, Edgware, HA8 8NB | Tel: 0300 033 7861 | Fax: 0300 033 7866

Current time is 12:19 - We're open

Hendon Surgery, 42 Station Road, Hendon, NW4 3SU | Tel: 0300 033 7860

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Flu Vaccination Consent Form

I, the undersigned have read the information below and hereby give consent to have the flu vaccine, I also confirm that the following apply:

or you may also complete online consent form

Date
Date Format: MM slash DD slash YYYY
I, the undersigned have read the information below and hereby give consent to have the flu vaccine, I also confirm that the following applyI also confirm that the following apply*
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- I am NOT allergic to egg or chicken protein
- I am NOT allergic to antibiotics (neomycin or polymycin)
- I am NOT allergic to mercury compound (thiormersal)
- I do NOT have a fever or think that I may be getting a fever
- I have NOT had a serious reaction to any flu vaccine in the past
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	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously