Flu Vaccination Decline Form

Flu 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 this years flu vaccination for the following reason: *

I have already had my vaccination at a pharmacy (XaZfY)

I have already had my vaccination by a different healthcare provider (XaZ0e)

I do not believe in the vaccine (XaZ0i)

I am unable to get to the surgery due to health reasons)

OtherOther

Please state which pharmacy you had your vaccination at: *

Please state which healthcare provider you had your vaccination at: *

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.

Signature

Clear

Privacy Policy

Health A-Z

Live Well

Medicines Guide

Care & Support

Willow Green Surgery

Contact Us