Kinsealy Medical Centre

Patient Forms Portal

Form Submitted

Thank you. Your shingles vaccine consent form has been received by Kinsealy Medical Centre.
Please now contact us by phone on (01) 840 5940 or by email at kinsealymedicalcentre@protonmail.com to book your appointment.
Your nurse will go through the form with you on the day.

Remember that Shingrix is a two-dose course. We will arrange your second dose for about 2 months after the first.

Patient Consent

Shingles Vaccine
Consent Form

This form collects your consent for the shingles vaccine (Shingrix) at Kinsealy Medical Centre. It includes information based on HSE and National Immunisation Advisory Committee (NIAC) guidance. Please read each section carefully before signing. Please complete a new form for each dose.

Want to read about cost, who the vaccine is for and possible side effects first? See our Shingles Vaccine page.

💉

Before You Begin

Please complete this form first, then contact us by phone on (01) 840 5940 or by email at kinsealymedicalcentre@protonmail.com to book your appointment. Shingrix must be ordered in specially for each patient. If you are unwell with a fever on the day, or currently have a shingles rash, please call us on (01) 840 5940 to rearrange.

1

Patient Details

Personal information

Please enter your full name.
Required.
Optional
Please enter a valid email address.
Required.
Required.
Required.
Required if you are not a registered patient, so we can create a file for you.
Please enter your home address.
2

About the Shingles Vaccine

Please read before completing the consent sections

💉 Shingrix at a glance

Shingrix is a non-live (recombinant) vaccine that protects against shingles and the long-lasting nerve pain it can leave behind (post-herpetic neuralgia). It does not contain live virus and cannot give you shingles.

  • Two doses are needed. The second is usually given 2 months after the first, and can be given up to 6 months after.
  • In clinical trials, two doses were more than 90% effective at preventing shingles in adults aged 50 and over.
  • We recommend it for all adults aged 50 and over. NIAC specifically recommends it for everyone aged 65 and over, and for adults aged 50 and over (or 18 and over in some cases) whose immune system is weakened by illness or treatment.
  • The vaccine is only available privately in Ireland and is not covered by the medical card or Drug Payment Scheme. The cost at this practice is €450 for both doses.

⚠️ Possible side effects

Most side effects are mild to moderate and settle within 2 to 3 days.

Very common (more than 1 in 10 people): pain, redness or swelling at the injection site; tiredness; muscle aches; headache; chills; fever; nausea, vomiting, diarrhoea or stomach pain.

Common (up to 1 in 10): itching at the injection site; generally feeling unwell.

Uncommon (up to 1 in 100): swollen glands; joint pain.

Rare or very rare: allergic reactions including anaphylaxis. A slightly increased risk of Guillain-Barré syndrome (about 3 extra cases per million doses in people aged 65 and over) has been reported.

More information: HSE: Shingles · HSE: Vaccine patient information leaflets · NIAC Guidelines, Chapter 23 (PDF)
3

Which Dose?

Tell us where you are in the course

Please choose which dose.
4

Health Questions

Your nurse will review these before giving the vaccine

Ticking any of these does not necessarily mean you cannot have the vaccine. It helps your nurse decide whether it is suitable today or whether you should speak with a doctor first.
5

Consent & Acknowledgements

Please read and tick each statement

Vaccine Consent

Side Effects & Observation

Data Consent

6

Patient Signature

Sign to confirm all sections above

Patient Signature

By signing, I confirm that I have read, understood, and consented to all statements in this form, and that the information I have given is accurate to the best of my knowledge. I understand I can withdraw consent at any time before the vaccine is given by telling my nurse.

Sign here

Vaccine record: After your vaccine you will receive a record of the dose given, including the date and batch number. Please keep it safely.