Flu Vaccination Form

You may be eligible for a free NHS Flu Vaccination this year. If you would like to register your interest in the seasonal flu vaccination please complete this form, we also ask that you use this form to decline the vaccination should you feel you do not wish to attend this year. This form is available 24/7.

We would like to specify that to be considered for a home vaccination you must be medically housebound; meaning that you are unable to attend the surgery or hospital without ambulance assistance, and have all your healthcare needs catered for in the home. Patients without transport are not considered medically housebound.

Flu Vaccination Form
Who is completing this form?

Please provide your contact details:

Patient Details:


Please confirm:
Thank you for expressing your interest in the NHS Flu Vaccination this year. The following are the proposed dates for the NHS Flu Vaccination Clinics.

The below dates are dates for our flu vaccination clinics, as there are three types of flu vaccination please ensure you have selected a date relating to your age group.

If left unselected you will be allocated to the next available flu clinic.

Please select your preferred date:
Thank you for informing us you would like the District Nurses to carry out your vaccination.

We would like to confirm this is a referral to the District Nurses who must be contacted if there are any issues or delays with the vaccination, not the surgery itself.