Request a flu vaccination

Section

The practice can send a text message to your phone with your appointment time. *

I agree to the practice sending me text messages including appointment times

I do not agree to the practice sending me a text message with my appointment time

Please select the appropriate category: *

Over 65 years old

Under 65 years who are clinically extremely vulnerable

Clinically extremely vulnerable eligibility includes patients with Chronic Heart, Kidney, Liver, Respiratory or Neurological Disease, have Diabetes, are Immunosuppressed or Morbidly Obese.

You must specify which risk group you are in: *

You are pregnant

You have certain medical conditions (examples listed above)

You receive a carer’s allowance, or you are the main carer for an elderly or disabled person whose welfare may be at risk if you fall ill

Terms & Conditions

I understand I must not attend if I am unwell or have any of the following symptoms:
- A new cough
- High temperature
- Loss of taste or smell
I understand if I am unwell or have any of the above symptoms I must contact the Medical Centre by telephone for advice.
I understand that the practice may need to send me a secure online message about my appointment. I will check my emails.
I confirm the appointment request is routine and may take up to 2 working days to process.

Signed: *

Date:

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Section

Under 65 years who are clinically extremely vulnerable

Terms & Conditions