Flu Vaccination Appointment Request

If you fall into one of the categories eligible for a flu vaccination, please complete this form.

We will then contact you to arrange an appointment.

Flu Vaccination Appointment Request

Flu Vaccination Appointment Request

Section

If you are using a UK mobile number, please use the format 07xxxxxxxxx

Smoking status:

Smoker

Would you like help to give up smoking?

Ex Smoker

Do you vape?
For applicable devices

Eligibility

If you would like to have the vaccine, please choose the appropriate option below and you will be contacted when your age group is eligible: *

Please note that your cohort may not be eligible for several months.

*