Over 65 Flu Consent Form

Please complete this form to let us know whether you would like the Flu vaccine this year or if do not wish to have the vaccine.

Over 65 Flu Vaccination Programme Consent Form

To offer patients an alternative method of booking or requesting a flu vaccination we are giving you the opportunity to book your vaccination direct through the link sent to you by SMS or via our main switchboard telephone 01909 721 206 or simply by completing and submitting the below consent or decline form.

Once the form has been submitted a member of the team will contact you with dates and times of your appointment.

Do you wish to have the Flu Vaccination? *

For Patients Who Wish To Have The Vaccine

When we receive your form, we will contact you with an appointment time if you're eligible.

If you cannot make the appointment, you will need to call us to rearrange.

Preferred place of vaccination *

For Patients Who Do Not Wish To Have The Vaccine

We will record this on your records.

If you change your mind later in the year, you are welcome to ask for the vaccine, but we cannot guarantee we will still have supplies.

*