Flu Vaccination Form

If you would like to express interest in getting a flu vaccination or if you would like to let us know that you do not want a vaccination, please complete this form.

Flu Vaccination Form

Text consent:

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

Who is the Appointment For

Please confirm who the appointment is for:

Ethnic group:

Please specify the group you consider yourself to belong to: *


You’re eligible for a free NHS flu vaccination if you fall into one of the below categories. Please tell us which of the following apply to you:

Please tick this box if you do not want the flu vaccine: