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Request an Appointment for Flu Vaccination

Complete this form to request an appointment for flu vaccination in your chosen totalhealth Pharmacy.

The information requested below will allow the pharmacist to quickly assess the safety and suitability of flu vaccination for each person. This also means the pharmacist can determine which vaccine is most suitable, and whether you can avail of free vaccination. Providing this information to the pharmacy in advance will also limit the amount of time you need to spend in the pharmacy, keeping you and our pharmacy teams safe.

More information on Pharmacy Flu Vaccination is available here.

Please note: completing this form and submitting a request for booking does not guarantee an appointment. The pharmacy will contact you as soon as possible to confirm if an appointment is available. You will receive a confirmation email after you send your completed form - please check your spam/junk folder if you do not receive it.

All fields or questions marked with * are required. Failure to complete all required information will lead to delays.
Choose your Pharmacy *

Complete this form in full to submit a request to your chosen totalhealth Pharmacy for a Flu Vaccination appointment

Please indicate whether you are completing this form for yourself or someone else *
For Myself
For a Child or Dependent
For Someone I Care for
Your Full Name (if requesting on someone else's behalf)
What is your relationship with the person requesting vaccination?

Personal Details for the Person Requesting Vaccination

Full Name (First Name and Surname) *
Email Address *
Date of Birth of the person requesting vaccination (DD/MM/YYYY) *
Contact Telephone Number *
Eircode *
Address *
PPS Number for the person requesting vaccination *
GP or Doctor Name and Surgery *

The following medical questions will allow the pharmacist to make sure that vaccination is safe and suitable

Is the person requesting vaccination currently feeling unwell in any way? *
Yes
No
Is the person requesting vaccination allergic to eggs or chicken? *
Yes
No
Has the person requesting vaccination ever suffered from anaphylaxis (allergic) attack? *
Yes
No
Is the person requesting vaccination pregnant or possibly pregnant? *
Yes
No
Has the person requesting vaccination ever had breast surgery? *
Yes
No
Has the person requesting vaccination ever had an allergic reaction to any vaccination? *
Yes
No
Does the person requesting vaccination have a history of asthma? *
Yes
No
Is the person requesting vaccination currently on steroid treatment? *
Yes
No
Is the person requesting vaccination currently taking antiviral influenza medication? *
Yes
No
Does the person requesting vaccination currently take aspirin or other salicylate medication? *
Yes
No
Is the person requesting vaccination immunosuppressed? *
Yes
No
Does the person requesting vaccination live, or have regular contact, with an immunosuppressed person? *
Yes
No
Has the person requesting vaccination received a flu vaccination before? *
Yes
No
Please select the location(s) of any previous flu vaccinations received
GP/Doctor Surgery
Pharmacy
Workplace/Occupational Health provider
Other
Does the person requesting vaccination suffer from any medical conditions? *
Yes
No
Please list any medical conditions suffered by the person requesting vaccination
Does the person requesting vaccination take any medication? *
Yes
No
Please list any medications currently being taken by the person requesting vaccination
Does the person requesting vaccination suffer from any known allergies? *
Yes
No
Please list any known allergies for the person requesting vaccination

Some people may be eligible for free Flu Vaccination. Please select Yes if any of the following applies for the person requesting vaccination

Is the person requesting vaccination in any of the HSE groups eligible for free vaccination? *
Yes
No
Unsure
Please indicate which HSE group applies (if applicable)
Aged 65 or over
Aged 2 to 17 years
Pregnant
Chronic Illness with high risk from flu infection
Body Mass Index (BMI) of 40 or more
Immunosuppressed
Child with neurodevelopment disorder
Child on long term aspirin therapy
Born with Down syndrome
Works in healthcare
Carer for chronic illness sufferer
In regular contact with pigs, poultry or waterfowl

Privacy Notice: By completing and sending this form, you agree that your information will be sent to your chosen totalhealth Pharmacy, who will use the details you provided to contact you and organise an appointment if available. Your information is not stored on this website. Click SEND to submit this form to your chosen pharmacy.

* Denotes required field

 
 
 
 
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