Consent Forms for Translating

HPV Vaccination Consent Form


This information is important. If you are unsure, please check with your
GP or red book.


Medical History
Does your child have any severe allergies?
No
Yes
Does your child have any existing medical conditions?
No
Yes
Does your child take any regular medication? (excluding contraceptive medication)
No
Yes
Is your child under the hospital for any treatment?
No
Yes
Has your child had any allergic reaction to any previous vaccination?
No
Yes
Has your child had the HPV vaccination before?
No
Yes
Does your child have a disease or treatment that severely affects their immune system? (e.g.
treatment for leukaemia)
No
Yes

Diptheria, Tetanus & Polio (Td/IPV) / Meningococcal ACWY Vaccination Consent Form


This information is important. If you are unsure, please check with your GP or red book.


Medical History
Is your child up to date with their primary and pre-school doses of diphtheria, tetanus and polio?
No
Yes
Has your child received any Tetanus, Diphtheria & Polio in the last 5 years? (Please note they may
have had as travel vaccine or at hospital or GP following a dirty open wound or animal bite)
No
Yes
Has your child had the Meningitis ACWY vaccination since the age of 10 years old? This is nonroutine vaccine given to those at risk due to: asplenia, primary immunodeficiency or sickle cell
disease; additionally, travel to Sub-Saharan African continent or Umrah/Hajj Saudi Arabia.
No
Yes
Has your child had any allergic reaction to any previous vaccination?
No
Yes
Does your child have any severe allergies?
No
Yes
Does your child have any existing medical conditions?
No
Yes
Is your child under the hospital for any treatment?
No
Yes
Does your child take any regular medication? (excluding contraceptive medication)
No
Yes

Measles, Mumps and Rubella (MMR) Vaccination Consent Form


This information is important. If you are unsure, please check with your
GP or red book.


Medical History
Does your child have any allergies including, neomycin or gelatine?
No
Yes
Does your child have any chronic or long term medical conditions? (i.e. cancer, leukaemia, immune
deficiency, lymphoma, colitis etc.)
No
Yes
Does your child take any regular medication? (excluding contraceptive medication)
No
Yes
Has your child had a confirmed anaphylactic reaction to any previous dose of measles, mumps or
rubella containing vaccine?
No
Yes
Has your child received a blood or plasma transfusion, immunoglobulin or been told you have a low
platelet count in the last 3 months?
No
Yes
Has your child had any other vaccinations in the last 4 weeks or planning to have any vaccinations in
the next month? (especially Varicella or Yellow Fever vaccination)
No
Yes

Flu Vaccination Consent Form 


I consent for my child to receive the Nasal Flu vaccination:
Yes
No
Full Name (Parent/guardian with parental responsibility)
Relationship to child
Please choose…
Has your child already had a flu vaccination in the last three months?
No
Yes
Has your child been diagnosed with asthma?
No
Yes
Does your child have a disease or treatment that severely affects their immune system? (e.g.
treatment for leukaemia)
No
Yes
Is anyone in your family currently having treatment that severely affects their immune system? (e.g.
they need to be kept in isolation)
No
Yes
Does your child have a severe egg allergy which has required hospitalisation or anaphylactic
treatment?
No
Yes
Is your child receiving salicylate therapy? (i.e. aspirin)
No
Yes
On the day of vaccination, please let the immunisation team know if your child has been wheezy in
the past three days. The nasal flu vaccine contains products derived from pigs (porcine gelatine).
More information for parents is available from www.nhs.uk/child-fl

Leaflets in other languages