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The Downland Practice NHS GP Surgery in West Berkshire

RSV vaccination consent

Pre-vaccination screening

Please answer each question. All answers must be reviewed by the appropriately authorised healthcare professional before vaccination.

Have you ever had a severe allergic reaction, including anaphylaxis, to a previous vaccine or to any component of a vaccine? *

Yes

Tell us about the allergic reaction: *

Have you been told by a healthcare professional that you should not receive an RSV vaccine or a particular vaccine component? *

Yes

Tell us about the advice you were given: *

Are you pregnant? *

Yes

Not applicable

Are you at least 28 weeks gestation? *

Yes

Have you had Guillain-Barre syndrome in the past 6 weeks? *

Yes

Tell us about your diagnosis:

If you are unwell and have a fever (temperature) on the day of your vaccination appointment, please contact reception to reschedule your appointment.

Consent *

I consent to receive the RSV vaccination, subject to the final eligibility and clinical assessment.

I do not consent to receive the RSV vaccination.

Please select one option.

Patient declaration *

I confirm that I have answered the questions above to the best of my knowledge. I understand that a trained registered healthcare professional will complete the final eligibility and clinical assessment before vaccination.

If you are human, leave this field blank.

East Lane
Chieveley
Newbury
Berkshire
RG20 8UY

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01635 248251

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