Phone: +353 21 431 0311
Email: info@uqmc.ie
Mon-Fri: 8:30AM - 6:00PM Sat: 9AM - 1PM

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Flu Vaccination Consent form

Union Quay Medical Centre

1
Step 1
Personal details
2
Step 2
Medical Check
3
Step 3
Submit

Step 1

Personal details

Full Name *

Date *

Address Form

Address 1

Address 2

City

Country

Email Address *

Phone *

Female

Are you pregnant?

Yes

Step 2

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

Past Reaction to any Vaccine *

Yes

Currently Feeling Unwell *

Yes

On Steroids *

Yes

Suppressed Immune System *

Yes

History of Infectious Jaundice *

Yes

Allergy to Eggs *

Yes

Any Known Allergies *

Yes

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.

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About Us

Union Quay Medical Centre is located in Union Quay in Cork city directly across from Cork College of Commerce and alongside the Cork School of Music. There is on street “pay & display” parking available outside.

Phone: +353 21 431 0311

Email: info@uqmc.ie

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

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