Decline Covid Booster

Covid Booster Decline Form

First Name *

Last Name *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

First line of address

Pode Code

Phone Number *

I wish to decline the Covid Booster vaccination for the following reason: *

I do not wish to have the vaccine (Y2efc)

I already have my vaccination booked elsewhere

Please state where you have your appointment booked: *

So we can keep your records up to day, please give a short reason for your decline:: *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

I consent to the practice collecting and storing my data from this form.

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