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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

I would like to decline my flu jab for this Autumn because: *  
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  
Fields marked with an asterisk (*) are mandatory