Flu Pre-Vaccination Questionnaire 2021
Please complete this form on the day of your vaccination, once submitted you will receive a QR code by email. Please present the QR code to the nurse or doctor who is administering your vaccine
Name*
Address*
Street Address Line 2
State / Province
Mobile Number*
Daytime Number
Date of birth*
Day Month Year
Company Name*
Occupation
Email*
Email Confirmation*
The email addresses do not match
We are commited to protecting your privacy when dealing with personal and sensitive information and will only collect and use personal data in a way that is consistent with our obligations and your legal rights. We will never sell, copy or generally distribute your personal data. We do sometimes need to share your information with other people or organisations for the purposes set out in our privacy notice. See our full privacy notice at www.fleetstreetclinic.com/privacy-cookies/
Flu vaccine takes 10 to 21 days to reach full effectiveness and immunity typically lasts nine months. The main seasonal flu strains change each year; the vaccine you are about to receive conforms with latest seasonal flu recommendations from the World Health Organisation.

Seasonal flu vaccine is extremely safe, but to minimize the possibility of harmful effects, please read and answer the following questions carefully:*

	Yes	No	N/A
Are you feeling unwell today or experiencing Covid-19 like symptoms?
Will this be your first ever flu vaccination?
Have you ever had an allergic reaction to Egg or Chicken Protein?
Or to Gentamicin, Polymixin, Kanamycin or Neomycin (rarely-used Antibiotic)?
Have you had an abnormal reaction to any previous flu immunisation?
Have you ever had any serious allergic reaction?

Optional question*
Yes No N/A
Are you Pregnant? (the Flu vaccine is safe and recommended in pregnancy, this information is for our records)
Signature*
Clear
Date*
Day Month Year
Given By :*
Site :
Signature*
Clear
Date*
Day Month Year
Vaccine Batch Number*
FLU266/QM/v9.0/i.09.2020/r.08.2021
Should be Empty:

Flu Pre-Vaccination Questionnaire 2021