Full Name *		Sex	Male Female Other
DOB *		Age *
Phone *		Email *
Address
GP Surgery		Consent to share info with GP if required	Yes No

Clinician has checked correct details*	Yes No
Consent to storage of health information	Yes No

*Good practice to check that contact details are correct and current.

Client is able to consent *	Yes No
Client is accompanied by someone able to consent on their behalf*	Yes No N/A

*(Mother, father or other adult with parental responsibility, legal guardian or person with lasting power of attorney).

Details of person consenting on behalf of another
Name		Relationship / legal status
Address

The client is happy to go ahead with the consultation and treatment. The clinician will explain the recommended treatment, including relevant benefits, potential side effects, and appropriate measures for managing any adverse reactions. *

Yes No

Use this information with the PGD document to decide if treatment can be supplied / administered. Refer to the GP/specialist if needed.

Are you feeling unwell today?	Yes No
Do you have any allergies, particularly to eggs or chicken protein?	Yes No
Have you ever reacted to a previous yellow fever vaccine?	Yes No
Do you have cancer or have you had cancer in the past?	Yes No
Do you have any illness that might affect your immune system? (e.g. leukaemias, lymphoma, cellular immune deficiencies, chronic lymphoproliferative conditions, or stem cell transplant)	Yes No
Are you living with HIV?	Yes No
Are you taking any medicines (now or within the last year) that affect your immune system? (e.g. steroids, biological/non-biological immune modulating medicines, organ transplant treatment)	Yes No
Are you having chemotherapy or radiotherapy (now or within the last year)?	Yes No
Have you ever been told that you may have a problem with your thymus gland (includes myasthenia gravis or a thymoma)?	Yes No
Have you had an operation to remove your thymus gland (thymectomy) for any reason including during cardiac surgery?	Yes No
Have you ever had open chest surgery?	Yes No
Are you pregnant or planning a pregnancy?	Yes No
Are you breast feeding?	Yes No
Do you have a first-degree family relative (mother, father, full brother, sister or child) who has had a serious adverse reaction to yellow fever vaccine?	Yes No

I confirm that the information I have provided is accurate and complete to the best of my knowledge. I agree to follow directions given by the healthcare professional. I agree to notify the service of any relevant changes to my health.

Information provided is accurate and complete
I agree to follow directions given by the healthcare professional
I agree to notify the service of any relevant changes to my health

Name of patient		Date
Signature of patient	Sign here Clear

Name of parent / guardian		Date
Signature of parent / guardian	Sign here (if applicable) Clear