Step 1

Personal details

Full Name *

Date *

Address Form

Address 1

Address 2

City

Country

Email Address *

Phone *

Female

Are you pregnant?

Yes

No

Step 2

Medical Checklist

Past/Current Medical problems. (Please List) *

Are you taking any medication ? . (Please List) *

CHECKLIST: PLEASE TICK THE FOLLOWING:

Please list allergies if any:

Sign/submit

I have decided that I wish to take recommended vaccine for Influenza Vaccine

I understand that by accepting the vaccine I am aware of possible complications and/or side affects.

Name *

Date: *

Signature *

I agree to the Privacy Policy

Form Submitted Successfully!

We will contact you as soon as possible.

Phone: +353 21 431 0311

Address: 1A Union Quay, Cork.

Mon-Fri: 8:30AM - 6:00PM Sat: 9AM - 1PM

Flu Vaccination Consent form

Union Quay Medical Centre

Step 1

Step 2

Medical Checklist

CHECKLIST: PLEASE TICK THE FOLLOWING:

Sign/submit

Form Submitted Successfully!

About Us

Parking & Location

Useful Links

Contact Information

Phone: +353 21 431 0311

Address: 1A Union Quay, Cork.

Mon-Fri: 8:30AM - 6:00PM Sat: 9AM - 1PM

Union Quay Medical Centre

Step 1

Step 2

Medical Checklist

CHECKLIST: PLEASE TICK THE FOLLOWING:

Sign/submit

Form Submitted Successfully!

About Us

Parking & Location

Useful Links

Contact Information

COVID VACCINE APPOINTMENT