Shingles vaccination consent

Medical screening questions

Please answer every question. All answers must be reviewed against the current Shingrix PGD and by the appropriately authorised healthcare professional before vaccination.

Have you ever had a severe allergic reaction, including anaphylaxis, to a previous shingles vaccine, another vaccine or any of its ingredients?

Yes

No

Tell us about the allergic reaction:

Do you have a known allergy to any component of the Shingrix vaccine?

Yes

No

Tell us about the allergy:

Have you previously been advised by a healthcare professional not to receive a shingles vaccine?

Yes

No

Tell us about the advice you were given:

Have you had a significant reaction after a previous vaccination that required medical assessment or treatment?

Yes

No

Tell us about the reaction:

Do you have a condition or treatment that significantly affects your immune system?

Yes

No

Tell us about the condition or treatment:

Are you pregnant, or could you be pregnant?

Yes

No

Not applicable

Not sure

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 Singles vaccination, subject to the final eligibility and clinical assessment.

I do not consent to receive the Shingles vaccination.

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.

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Medical screening questions