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 blue, passport-style 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.

Want to review the full immunisation schedule, side effects, or RSV vaccine timing first? See our Childhood Immunisations page.

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Before You Begin

Please tell your nurse on the day 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 (the blue, passport-style 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

RSV vaccine — timing depends on your baby's birth month

Babies born during RSV season (September–February) are usually immunised against RSV at birth in the maternity hospital. If your baby was born outside that window, we give it here at the practice instead, timed to a routine visit so your child is protected before the next RSV season begins:

Baby born inRSV vaccine given at
March6-month Primary Childhood Immunisation visit
April4-month Primary Childhood Immunisation visit
May4-month Primary Childhood Immunisation visit
June2 or 4-month Primary Childhood Immunisation visit
July2-month Primary Childhood Immunisation visit
August2-month Primary Childhood Immunisation visit (or the 2- or 6-week check under the Mother & Infant (M&I) scheme)

Your nurse will confirm whether RSV vaccination applies at today's visit.

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.

Key: PCV = Pneumococcal Conjugate Vaccine, MenB = Meningococcal B vaccine, MenC = Meningococcal C vaccine, Hib = Haemophilus influenzae type b vaccine.

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
6-in-1PCV

Third dose of the 6-in-1 and second PCV dose.

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

MMR protects against measles, mumps and rubella — this is a live vaccine. Chickenpox vaccine applies to babies born on or after 1 October 2024 — your nurse will confirm.

13 months
PCV, MenC, 6-in-1 (4th dose)
PCVMenC6-in-1 (4th dose)

Final booster dose of the primary schedule. MenC is given separately at this visit, and a 4th dose of 6-in-1 provides extra Hib protection.

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 confirm each statement below for your child

Please read each statement and tick to confirm. If you cannot confirm any statement below, please do not tick it — tell your nurse before any vaccine is given, so they can assess whether the vaccine should go ahead today.

Health Status — Please Confirm Each Statement

Ongoing Commitment

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 blue, passport-style immunisation record book will be updated with the vaccines given, including dates and batch numbers. Please keep this document safely.