Decline the Influenza Vaccination

Please complete this form, if you DO NOT, wish to receive the flu vaccination. Your medical records will be updated to reflect your decision.

Please note the flu vaccine has to be declined every year or we will continue to invite you.

Decline Flu Vaccination

First Name *

Last Name *

Email *

Please ensure you enter your correct email address

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Confirm your preference for influenza vaccination

I wish to decline the influenza vaccination

Privacy Policy

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.

I consent to the practice collecting and storing my data from this form.

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Decline the Influenza Vaccination

Privacy Policy

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