Decline Your Flu Jab

Please complete this form if you do not want your flu jab this year. If you change your mind, you can still have your flu jab – simply contact the surgery.

Your Details

Full Name *

Date of Birth *

Address *

Email Address *

Home Telephone Number *

Mobile Number

I would like to decline my flu jab for this Autumn because: *

Date *

I take full responsibility for declining my flu jab and the impact this could have on my health *

How do we contact you?

Please confirm if you would be happy for the surgery to communicate with you by e-mail

I would like to receive text reminders

I want a copy of the contents of this form to be emailed to me

I confirm that I am a registered patient at Everglade Medical Practice *

Fields marked with an asterisk (*) are mandatory

FAQs

About This Form

Please note that we will not respond to any medical information or questions received through the survey.

The information you supply us will be used lawfully, in accordance with the Data Protection Act 1998. The Data Protection Act 1998 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Please note that by using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.

Are my details secure?

The internet is not a secure place, however, we have gone to great steps in making sure the information you submit to us is as secure as possible.

We use SSL (Secure Socket Layer) certificates to encrypt the communication between your computer and our web server. When you submit your information, it is safely transmitted over the web in an encrypted form and deciphered using the private key at its intended location.

Decline Your Flu Jab

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