Jai Medical Centre (Brent)

Staglane Location: 82 Stag Lane, Edgware, HA8 5LP | Tel: 0300 033 7863 | 020 8952 8583

Current time is 15:06 - We're open

Sheldon Location: 19 Chichele Road, London, NW2 3AH | Tel: 0300 033 7864 | 0300 033 5816

Current time is 15:06 - We're open

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Consent 2020/21 Flu Vaccination

You are here:
Home
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Consent 2020/21 Flu Vaccination

Consent 2020/21 Flu Vaccination

Information about the 2020/21 Flu Vaccination

Flu vaccination Consent form

I, the undersigned have read the information below and hereby give consent to have the flu vaccine, I also confirm that the following apply:

I am NOT allergic to egg or chicken protein
I am NOT allergic to antibiotics (neomycin or polymycin)
I am NOT allergic to mercury compound (thiormersal)
I do NOT have a fever or think that I may be getting a fever
I have NOT had a serious reaction to any flu vaccine in the past

For more information on flu-influenza vaccine please click on the link

or you may complete the online consent form:

Flu Vaccination Consent form

Electronic Consent form

Date
MM slash DD slash YYYY
Flu vaccination Consent*
I, the undersigned have read the information below and hereby give consent to have the flu vaccine;
Flu Vaccination Consent
I also confirm that the following apply*
- Select All
- I am NOT allergic to egg or chicken protein
- I am NOT allergic to antibiotics (neomycin or polymycin)
- I am NOT allergic to mercury compound (thiormersal)
- I do NOT have a fever or think that I may be getting a fever
- I have NOT had a serious reaction to any flu vaccine in the past
Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
Phone*
Comments
This field is for validation purposes and should be left unchanged.

Update your Details

Order your Prescriptions

Online Appointment Booking

GDPR Patient Consent Form

Patient Registration Form

Patient Survey

Friends and Family Test

How we use your information

Brent Community Services

Jai Medical
(Brent)

Monday
08:00 until 18:30
Tuesday
08:00 until 18:30
Wednesday
08:00 until 18:30
Thursday
08:00 until 18:30
Friday
08:00 until 18:30
Saturday
CLOSED
Sunday
CLOSED

Jai Medical (Sheldon)

Monday
08:00 until 18:30
Tuesday
08:00 until 18:30
Wednesday
08:00 until 18:30
Thursday
08:00 until 18:30
Friday
08:00 until 18:30
Saturday
CLOSED
Sunday
CLOSED

Useful Links

GDPR Patient Consent Form

Date of Birth*
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Consent to use these details
Consent to use these details*
- Yes
- No
Consent to collect your medical data*
- First Choice
Under the GDPR we also need to gain your consent to allow other people to collect repeat prescriptions, any paper work on your behalf. This could be a Sick Certificate, Private Letter, Referral Letter or blood test results. On collection third party will need to provide proof of ID.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
Phone*
Consent*
I agree to the the above person having consent
Under the GDPR we also need to gain your consent to allow other people to collect repeat prescriptions, any paper work on your behalf. This could be a Sick Certificate, Private Letter, Referral Letter or blood test results. On collection third party will need to provide proof of ID.
Consent to collect your medical data
- Second Choice
Under the GDPR we also need to gain your consent to allow other people to collect repeat prescriptions, any paper work on your behalf. This could be a Sick Certificate, Private Letter, Referral Letter or blood test results. On collection third party will need to provide proof of ID.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Consent
I agree to the the above person having consent
Under the GDPR we also need to gain your consent to allow other people to collect repeat prescriptions, any paper work on your behalf. This could be a Sick Certificate, Private Letter, Referral Letter or blood test results. On collection third party will need to provide proof of ID.
Phone
This field is for validation purposes and should be left unchanged.

	Very easy	Fairly easy	Not very easy	Very difficult	N/A
Getting through on the phone
Speaking to a doctor on the phone
Speaking to a nurse on the phone
Obtaining test results by phone

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

	Very good	Good	Average	Poor	Very poor
Giving you enough time
Asking about your symptoms
Listening to you
Explaining tests & treatment
Involving you in decisions about your care
Treating you with care and concern
Taking your problems seriously

Jai Medical Centre (Brent)

Consent 2020/21 Flu Vaccination

Flu Vaccination Consent form

Jai Medical(Brent)

Jai Medical (Sheldon)

Useful Links

Update your Details

GDPR Patient Consent Form

Consent to use these details

Patient Registration Form

Patient Survey

Friends and Family Test

Jai Medical
(Brent)