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

Dear Patient,

As you are probably aware, this year will be a very challenging year for delivering the flu vaccine program.

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 online portal, SystmOnline or via our main switchboard tel 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 cannot make the appointment, you will need to call us to rearrange.

If you have online access, please click on the link to book an appointment.

Please note vaccinations for under 65 years of age will not be available until the 8th October 2020.

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.

*