Flu Vaccination Opt-Out Form

If you wish to opt-out of receiving a Flu Vaccination please let us know by completing this form and we will update your medical record.

Last Updated: 25/11/2021

Your Details

Name *

Address (Including Postcode) *

Date of Birth (DD/MM/YYYY) *

Contact Number *

Email Address *

Opt Out Details

If you are eligble do you wish to opt out of receiving this years flu vaccination? *

Yes No

Please tell us why? (optional)

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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Flu Vaccination Opt-Out Form

Further Information