Union Quay Medical CentreFlu Vaccination Consent form 1 Step 1Personal details 2 Step 2Medical Check 3 Step 3SubmitStep 1Personal details Full Name * MrMrsMsMiss Date * Address Form Address 1 Address 2 City Country Please SelectAfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo Verde IslandsCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprus NorthCyprus SouthCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFederated States of MicronesiaFijiFinlandFranceFrench GuianaFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovak RepublicSloveniaSolomon IslandsSomaliaSouth AfricaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrianTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayU.S. Virgin IslandsUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands - BritishWallis and FutunaWestern SaharaYemen (North)Yemen (South)ZambiaZimbabwe Email Address * Phone * Female Female Are you pregnant? Yes No Next Step 2Medical Checklist Medical Checklist Past/Current Medical problems. (Please List) * Are you taking any medication ? . (Please List) * CHECKLIST: PLEASE TICK THE FOLLOWING: Receive Flu vaccine previously * Yes No Past Reaction to any Vaccine * Yes No Currently Feeling Unwell * Yes No On Steroids * Yes No Suppressed Immune System * Yes No History of Infectious Jaundice * Yes No Allergy to Eggs * Yes No Any Known Allergies * Yes No Please list allergies if any: Previous Next 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 Previous Submit Form Submitted Successfully!We will contact you as soon as possible.