Consent to Childhood Immunisations - updated 2 May 2022

Use this form to confirm parental or guardian consent for Immunisations as part of the routine childhood immunisation schedule including: Diphtheria, Tetanus, Pertussis, Polio and Haemophilus influenza type B immunisation, Measles, Mumps, Rubella, Meningitis B, Meningitis C, Pneumococcus, Rotavirus, Hepatitis B, and Seasonal Influenza

Patient Details

The full name and date of birth of the child is required in order to book a Childrens Flu Vaccination appointment.

Patient Name *

Patient's Date of Birth *

Patient's NHS Number (if known)

Screening Questions

Screening Questions

Statement of Health Care Professional

At the clinic appointment one of our Health Care Professional will review the answers to the Screen Questions you have provided above are still valid. They will explain the benefits and risks of childhood immunisations. At the clinic appointment you will be asked to sign and confirm your agreement to the above Statement of Parental or Guardian consent for the above named patient to be immunised at the clinic appointment.

Statement of Parent / Guardian

Name of parent or guardian *

I am the mother / father / guardian of the patient on the birth certificate and have parental consent. If you DO NOT have parental consent, this episode of care needs to be postponed and you will need to bring a letter to the surgery for each contact of care from the person with parental consent. I have understood the information about the above immunisations including the risks of the vaccination and the risks of not being vaccinated and have been given the opportunity to discuss this. I request that the above named patient is immunised with the vaccines recommended in the routine childhood immunisation schedule. *

Yes No

(If applicable) I have asked the relative/childminder/friend named below to bring the above named patient for the vaccinations.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

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Consent to Childhood Immunisations - updated 2 May 2022

Further Information