Meningitis B Vaccine Consent Form

MenB Vaccination Consent Form

Patient Information

Name
Name
First Name
Last Name
Address
Address
Zip/Postal
City
Country

Eligibility For The One-Off MenB Programme

This appointment is for a single dose only. A second dose is required at least 28 days later, and must be booked separately online - it is not arranged as part of this form.

Tick the route that applies. Only one route needs to be met. This is a time-limited NHS-commissioned offer for those at highest risk ahead of the 2026/27 academic year - it is not a general catch-up for all ages.

Eligibility
Eligibility for this route is confirmed by date of birth alone (already captured in Section 1). No further documentary evidence is required per the service specification.
Proof to bring: evidence of an offer for higher education, issued by either UCAS or the university/college itself.
Proof to bring: evidence of residential further education entry, issued by one of the organisations listed on GOV.UK's list of eligible residential FE settings.
This patient is not eligible for the free one-off MenB programme under this pathway and cannot proceed.

Patient Information - Bexsero (MenB Vaccine)

Read the manufacturer's patient information leaflet for Bexsero before your appointment or while you wait: medicines.org.uk/emc/product/5168/pil

Two doses are needed for protection, given at least 28 days apart. Ideally both doses should be completed before the 2026/27 academic year starts. Common side effects include soreness/redness at the injection site, fever, headache and muscle aches, usually mild and short-lived.

Health Screening Questions

Answer based on how things stand on the day of your appointment where possible. Some answers (such as feeling unwell) can change closer to the date - these will be briefly reconfirmed with you in person before vaccination.
Has the patient ever previously received a MenB vaccination - including as part of the routine infant immunisation schedule, another outbreak-response clinic, or privately (in the UK or abroad)?
Any known allergy to a previous dose of Bexsero, or to any vaccine component (including latex)?
Currently unwell with a fever or acute illness?
Any bleeding disorder, or taking anticoagulant medication?
Weakened immune system (e.g. immunosuppressive treatment, HIV) or on high-dose steroids?
Pregnant, breastfeeding, or think you may be pregnant?
Any previous fainting or significant reaction to a needle or injection?
Received any other vaccine in the last few days, or planning one shortly?

Consent

I declare that...
Please enter your full name.