2026 Child Flu Vaccine

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Child Flu Vaccine

Children’s Nasal Flu Vaccine Consent Form 2026

Child’s First Name

Last Name

DOB

Address

Address Line 1

Address Line 2

County

Eircode

Parent/guardian’s first Name

Last Name

Parent/guardian mobile phone number (numbers only)

Parent/guardian e-mail address

Child’s PPS number (required)

Child’s class/teacher

Has your child ever received the flu vaccine before?

Yes

No

Has your child ever needed an Intensive Care Unit (ICU) admission following an allergic reaction to eggs ? (if yes please provide details)

Yes

No

Further details (max 255 characters)

Does your child have severe asthma needing ongoing oral steroids ? (if yes please provide details)

Yes

No

Further details of asthma (max 255 characters)

Does your child have a severely weakened immune system due to disease or treatment such as leukaemia/lymphoma or live with someone severely immunocompromised eg someone who has had a bone marrow transplant? (if yes please provide details)

Yes

No

Further details (max 255 characters)

Does your child have either a cochlear implant or a known metabolic disorder or take medication called checkpoint inhibitors eg Ipilimumab? (if yes please provide details)

Yes

No

Further details (max 255 characters)

Please write in the box below if there is any additional information about your child that you would like to share with the vaccination team. Please note the vaccination team may contact you by phone to clarify any of the answers given above.

I have read the HSE information leaflet on the children’s nasal flu vaccine. I agree that the details I have supplied will be recorded and those records will be kept by Maynooth Medical Centre and shared with the HSE only for the purposes of public health as required by legislation. By clicking on the box below you are digitally signing this consent form.

I am the child’s parent/legal guardian and I consent to them receiving the nasal flu vaccine

Consent confirmation

Maynooth Medical

Main Street, Maynooth, Co. Kildare, W23 E6P4
Above McCormack's Pharmacy
Phone: (01) 629 2556

Opening hours

Mon–Thu 9–12 & 2–5
Fri 9–12 & 2–4
KDOC — 045 848 701 (18:00–09:00 & weekends)

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