CHICKEN POX VACCINE CONSENT FORM

Please fill in the form below to give consent for therapy. Someone will call you to go over this and arange a date and time for the administration of these vaccines, if you do not already have this arranged.

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Name of recipient *

First

Last

Name of guardian (if patient is under 18)

First

Last

Address: *

Date of birth *

Email *

Best phone number to get you on *

Who is your primary care physician (GP) as we may need to talk to them about your request unless you opt out *

I will contact my GP myself, you do not have my permission to contact my primary care providers about my care.

• Tick here

I formally consent for Dickson Chemist to provide Chicken Pox Vaccination. I am aware that there may be side effects and that no injections or vaccinations are without risk, however small. I have read the patient leaflet here: https://www.medicines.org.uk/emc/product/5582/pil#gref *

• Agree

This therapy requires 2 injection 4-8 weeks apart. £135 per patient covers botjh injections. This is paid in store after the injections are administered, or beforehand if you booked on the website. Let us know which branch would be best to get the injections. Rutherglen, Bridgeton, Viewpark, Glenmavis, Whiteinch, Partick, Cambuslang 222, Cambuslang 154. *

I give informed formal consent for this therapy for myself, or my child. Type your name below. *

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