Covid flu vaccine form | Highland Pharmacy

Preferred Pharmacy

First name

Last name

Birthday

Day

Month

Year

Address

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Email

Phone Number

Please choose which services you would like? Links to further information on NHS eligibility is available on our Flu and covid page.

Private Flu £21.99

Private Covid £95

Free NHS FLU- Service Ends 31st March 25

Free NHS Covid- Service ends 31st Jan 25

GP Name/ Practice

Have you had a high temperature or fever in the last 24hrs?

Yes

No

Have you ever had an allergic or anaphylactic reaction to an influenza vaccine or any other vaccine before?

Yes

No

Women only: Are you pregnant, or is there any possibility that you could be pregnant?

Yes

No

Women only: Are you currently breast-feeding?

Yes

No

Are you immunosuppressed due to disease or treatment?

Yes

No

Do you have a bleeding disorder, including taking any medication that thins your blood (anticoagulants)?

Yes

No

Are you likely to come into close contact with severely immunocompromised patients?

Yes

No

Do you feel any stress related reactions (e.g. feeling faint) when receiving a vaccine?

Yes

No

Please confirm the following statements.

I understand the vaccine may not fully protect everyone who receives it.

I understand common side effects are mild and get better within 1 to 2 days.

They can include:

More serious side effects are very rare. The person who vaccinates you will be trained to deal with allergic reactions and treat them immediately.

The injected flu and covid vaccines used do not contain live flu viruses. They cannot give you flu or covid.