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Brook Square Surgery NHS GP Surgery in Scarborough

Flu vaccination

Flu Vaccination Form

Section

I wish to attend for a Flu vaccination, and I understand that I will get an email to advise me of the time I should attend

I wish to decline a Flu vaccination

I confirm that I would like a Flu vaccination

Eligibility:

You’re eligible for a free NHS flu vaccination, if you fall into one of the below categories. Please tell us which of the following apply to you: *

I am over 65 years

I am pregnant

I have a lung condition such as COPD, emphysema or bronchitis

I have severe asthma requiring the use of a steroid inhaler or tablets

I have chronic heart disease

I have chronic kidney disease

I have a chronic neurological condition e.g. Parkinson’s disease, motor neurone disease, multiple sclerosis or cerebral palsy

I have a learning disability

I have diabetes

I have Splenic dysfunction or asplenia

I have a weakened immune system due to disease (such as HIV/AIDS) or treatment (such as cancer treatment)

I am morbidly obese (defined as a BMI of 40 and above)

I am a Child aged under 4 years of age

I am aged 50-64

I am a registered carer

I am under 18 years of age

I am unsure if I am eligble

I wish to decline the Flu vaccine

Please provide more information:

If you are human, leave this field blank.

Trafalgar House
41-44 Trafalgar Street West
Scarborough
YO12 7AS

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01723 360 098

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