2024/25 WINTER FLU VACCINATION REQUEST – FOR ALL ELIGIBLE PATIENTS

We accept Winter Flu Vaccination appointment booking through this form for the following Adults who:

· are aged 65 or over

· are at risk due to certain long-term health conditions *

· are pregnant

· are the main carer for an older or disabled person, or receive a carer's allowance

· live with someone who has a weakened immune system

Please note that frontline health and social care workers can get a flu vaccine through their employer.

* To establish if you are in an at-risk group, please download NHS Flu Risk Group information by following this link>>

Last Updated: 07/09/2024

About you

So we can link this request with your records.

Your full name *

Your date of birth (DD/MM/YYYY) *

THE CRITERIA UNDER WHICH YOU ARE ELIGIBLE *

I am aged 65 or older

I am aged 18 – 64 years of age and meet the "At Risk" eligibility criteria outlined by the NHS

I am pregnant

In receipt of carer's allowance, or are the main carer for an older or disabled person who may be at risk if I get sick

I live with someone who is more likely to get a severe infection due to a weakened immune system

If requesting as an "At Risk" patient, under which condition

HOW MAY WE CONTACT YOU?

Please let us know your contact details so we can confirm your appointment.

YOUR EMAIL ADDRESS *

YOUR MOBILE PHONE NUMBER

YOUR LANDLINE PHONE NUMBER

Any additional comments

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 . *

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2024/25 WINTER FLU VACCINATION REQUEST – FOR ALL ELIGIBLE PATIENTS

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