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Home
Appointments, Tests & Referrals
Appointments
Book an Appointment
Cancel an Appointment
Evening and Weekend appointments
Help with your GP Appointment
Hospital Appointments – Book, Cancel or Change
NHS 111 online – Get help for your Symptoms
Before My Appointment
Flu Clinic Appointments Season 20/21
On The Day
Pre-booked
Know Who to Turn to for Your Healthcare
Accident & Emergency
Dentist
Hospitals
NHS Out of Hours Services
Optician
Pharmacist
Referral for Further Care
See a Doctor or Healthcare Professional
Tests & Investigations
Access Your Test Results
IPSS (International Prostate Symptom Score)
Other Common Tests
Urine Tests
X-Rays & Scans
What is a Blood Test?
Who Do I See?
Clinics & Services
Clinics
Antenatal Care
Child Health Checks
Clinics we provide
Health Promotion Clinics
Long Term Conditions
NHS Health Check aged 40 – 74
Cryotherapy
Flu Clinics
Dermatology Services
Blood Tests
How to use eConsult
Online Services
Register for Online Services
Online Access
NHS App
Practice Services
Advocacy Service
Cervical Screening
Dementia Services
Diabetes Services
Hepatitis B Immunisation
Register with us as a New Patient
Housebound & Older People
Home Visits
Interpreting Service
New Medicine Service (NMS)
NHS screening
Non NHS Services – Chargeable
Order a Repeat Prescription
Anticipatory Anxiety
Antibiotic Use
Wasted Medications
Electronic Prescriptions
Patient Transport Service
Sick/Fit Note
Vaccinations
Texting Service
Social Prescribing
Sepsis
Your Record
NHS App Support
Keep us up to Date
Change of Contact Details Form
Subject Access Request (SAR)
Register as a Carer Form
Register for Online Services Form
Summary Care Record Opt-out Form
Communication Consent Form
Upload a Photo or File
Flu Vaccination Decline Form
Home Blood Pressure Monitoring
Decline Shingles Vaccination
Dissent from Secondary Use of GP Patient Identifiable Data
Annual Long Term Condition Online Review Forms
Asthma Review
COPD Annual Review
Hypertension Review
Cardiovascular Review
Contraception Review
Diabetes Review
For Care Home Use
About Us
Contact
Contact Telephone Numbers
Location
Signing Up For Patient Participation Group
Opening Hours
What to do when we are closed
Subject Access Request (SAR)
Send a Message
Teenager Portal
Have your Say
Practice Survey Reporting
Patient Participation Group
Compliments and Suggestions
Friends and Family Test
Complaints
Patient Opinion
Patient Participation Group
Making the most of your Practice
Our Team
Doctors
Patient Services / Administration
Nurses
Health Care Assistants & Phlebotomists
Paramedic Practitioners
Pharmacy Team
PCN Team
Practice Management Team
Our Allied Health Professionals
Patient Link
Practice Policies
At the Practice
Accessible Information Standard
Baby Friendly
Chaperones
Chaperone Policy
Clinical Governance
Clinical Research
Consent Protocol
Disability Access
Duty of Candour
Equality and Diversity
Infection Control Statement
Named GP Policy
Non-Smoking Premises
Quality Assurance
Removal of Patients from our List
Social Media
Safeguarding Children
Shared Decision Making
Unacceptable Actions Policy
Zero Tolerance
Data
Care Data
Freedom of Information
General Practice Extraction Service (GPES)
Your NHS Data Matters
Sharing Your Health Records
Patient Record
Accessing your Record
Access for Others
Access to Records
Subject Access Requests(SAR)
Data Sharing Preferences
Multi-Disciplinary Teams
Organ Donation
Sharing your Information with Others
Summary Care Records (SCR)
How we use your Data
Confidentiality
Privacy Policy
Online Access
Proxy Access
Patient Rights
Complaints
Entitlement to NHS Treatment
Patient Advice and Liaison Service (PALS)
NHS Patient Rights
Your Rights and Responsibilities
Website
Accessibility
Copyright
Cookie Policy
Disclaimer
Regulations & Governance
Clinical Commissioning Group
GP Earnings
Care Quality Commission (CQC)
NHS Services
The NHS Constitution for England
Can I see the GP or Nurse on my own?
Training Practice
PatientLink
WGPPG
Help & Support
Help & Support Organisations
Pain Management
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Willow Green Surgery
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Flu Vaccination Decline Form
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)
Other
Other
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.
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