Jai Medical Centre

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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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Edgware Surgery

	Very easy	Fairly easy	Not very easy	Very difficult	N/A
Getting through on the phone
Speaking to a doctor on the phone
Speaking to a nurse on the phone
Obtaining test results by phone

	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

	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