Yellow Fever Consent

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Personal Details
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Please answer the following questions as honestly as you can. The answers you provide will help the Nurse/Doctor to make a decision as to whether you are fit to receive the Yellow Fever vaccination today. Please select Yes or No. 

Are you feeling feverish today?: *
Do you suffer from any chronic illnesses such as diabetes, asthma?: *
Are you allergic to egg protein, gelatine or latex?: *
Are you, to your knowledge, HIV positive? : *
Do you have a thymus disorder - including myasthenia gravis, thymoma, thymectomy and DiGeorge Syndrome?: *
Could you be pregnant? : *
Are you breastfeeding?: *
Have you had chemotherapy or radiotherapy for malignant disease within the last 6 months?: *
Have you received a bone marrow transplant within the last 6 months?: *
Are you undergoing drug induced immune-suppression?: *
Have you received any other vaccines or treatment in the past 4 weeks?: *
Patient Consent

I have completed the above to the best of my knowledge, and I am happy to receive the vaccination

Privacy Consent

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