Pregnancy Vaccination Form

During pregnancy you are entitled to both the seasonal flu vaccination and a pertussis vaccination.

If you would like to have these vaccinations please complete this form and we will aim to get back to you within 48-72 hours.

If you are human, leave this field blank.

Are you currently pregnant?

Yes

You are not eligible to complete this form.

Are you between 16 to 32 weeks pregnant?

Yes

When is your estimated delivery date?

Would you like your free flu vaccination during your appointment (seasonal vaccination between September and March)?

Yes

Please specify a date and time you are available for an appointment:

I understand my request may not be viewed for up to 48 working hours and that vaccinations are a non-urgent request.

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