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Flu Vaccine
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Vaccine Services
Click on the images above to view more information on the Vaccines available in our Pharmacies
Fill out the Vaccine Questionaire below to Register for a Vaccine in one of our Pharmacies
Vaccine Questionaire
What Vaccine/s are you interested in? (Tick vaccines required)
Flu Vaccine
Covid19-Booster Vaccine
In which Pharmacy do you want to receive your vaccine?
Daarwood Pharmacy Newcastlewest
Southside Pharmacy Roxboro
Ballycasey Pharmacy Shannon
Woodview Pharmacy Cratloe
Email
Name
Address
Phone Number
Date of Birth
Your GP's Name & Address
PPS Number
Are you a Medical card Holder?
Yes
No
Select the category that applies as to why you require the Flu Vaccine
Aged 65 years and over
Aged between 2 years and 18 years old (Fluenz Nasal Spray)
Pregnant Woman
Healthcare Worker - Medical/Dental
Healthcare Worker - Nursing
Healthcare Worker - Health & Social Care Staff
Healthcare Worker - Management / Administration
Healthcare Worker - General Support Staff
Healthcare Worker - Other
A - Chronic Respiratory Disease
C - Chronic Heart Disease
D - Chronic Renal Failure
E - Chronic Liver Disease
F - Chronic Neurological Disease
G - Immunosuppressed (due to disease or treatment)
H - Household contacts or out of home carer ( to persons of increased medical risk)
I - Diabetes Mellitus
J - Morbidly Obese
K - Haemoglobinopathies
L - Children with conditions that compromise respiratory function
M - Resident of a nursing home or other long stay facility
O - Carers
P - People in close contact with pigs, poultry or water fowl
Q - Children on long term Aspirin therapy
AL - Down Syndrome
CN - Clinical risk necessity for a second dose
None of the above
Are you Pregnant?
Yes
No
Have you had breast surgery?
Yes
No
Are you allergic to Eggs or Chicken
Yes
No
Any you allergic to any of the vaccine residues or excipients?
Yes
No
Have you ever had an allergic reaction to a previous vaccination?
Yes
No
Have you ever suffered from an Anaphylaxis Reaction?
Yes
No
Please give details of any current medical conditions, allergies or are you taking any medicines?
Have you had any exposure to Covid 19 in the last two weeks?
Yes
No
Do you feel unwell in any way?
Yes
No
Have we partnered with your employer for you to receive the Flu Vaccine?
Yes
No
If you answered yes to the question above who is your employer?
Submit