Kinsealy Medical Centre

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Thank you. Your childhood immunisation consent form has been received by Kinsealy Medical Centre.
Laura or another member of our nursing team will review this with you at your appointment.

Please bring your child's immunisation record book (the yellow booklet) with you.

Parent / Guardian Consent

Childhood Immunisation
Consent Form

This form collects your consent, as parent or legal guardian, for your child's immunisation at Kinsealy Medical Centre, following the HSE Primary Childhood Immunisation Schedule. Please read each section carefully before signing.

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Before You Begin

Please tell your nurse today if your child is unwell, has had a previous reaction to a vaccine, was born prematurely, or has any ongoing medical condition. Bring your child's immunisation record book (yellow booklet) to every appointment.

1

Child's Details

Information about your child

Please enter your child's full name.
Required.
Optional — helps link your child's record
Required.
2

Parent / Guardian Details

The person consenting on the child's behalf

Required.
Required.
Please enter a valid email address.
Required.
3

Today's Visit

Select the immunisation visit your child is attending for

Not sure which visit applies? Select the age closest to your child's today, or "Catch-up / other" if this is a delayed or additional dose — your nurse will confirm exactly which vaccines are due.
2 months
6-in-1, PCV, MenB, Rotavirus (oral)
6-in-1PCVMenBRotavirus (oral)

The 6-in-1 protects against diphtheria, tetanus, whooping cough, polio, Hib and Hepatitis B. Given as injections plus an oral rotavirus drop.

4 months
6-in-1, MenB, Rotavirus (oral)
6-in-1MenBRotavirus (oral)

Second dose of the 6-in-1, MenB and oral rotavirus course.

6 months
6-in-1, PCV, MenC (if applicable)
6-in-1PCVMenC

Third dose of the 6-in-1 and second PCV dose. MenC at this visit applies to babies born before 1 October 2024 — your nurse will confirm.

12 months
MMR, MenB, Chickenpox (if applicable)
MMRMenBChickenpox (varicella)

MMR protects against measles, mumps and rubella — this is a live vaccine. The chickenpox vaccine applies to babies born on or after 1 October 2024.

13 months
PCV, Hib/MenC or 6-in-1 (4th dose)
PCVHib/MenC6-in-1 (4th dose)

Final booster dose of the primary schedule. The exact combination depends on your child's date of birth — your nurse will confirm which apply today.

Catch-up / other
A delayed, additional, or non-standard dose

Please describe below which vaccine(s) this appointment is for.

4

Health Screening Today

Please tick all that apply to your child

Some circumstances mean a vaccine should be delayed or given with extra care. Please answer honestly — your nurse will review this before any vaccine is given.

Health Status — Please Tick All That Apply

5

General Consent & Acknowledgements

Please read and tick each statement

Consent to Vaccinate

Post-Vaccination Observation

Side Effects & Adverse Reactions

Data Consent

6

Parent / Guardian Signature

Sign to confirm all sections above

Signature

By signing, I confirm I am the parent or legal guardian of the child named above, that I have read, understood, and consented to all statements in this form, and that the information I have provided is accurate to the best of my knowledge. I understand I can withdraw consent at any time before a vaccine is administered by informing my nurse.

Sign here

Immunisation record: After vaccination today, your child's yellow immunisation record book will be updated with the vaccines given, including dates and batch numbers. Please keep this document safely.