Flu Vaccine Appointment Request form Your details Note: Questions marked by * are mandatory *This is a mandatory field. First name *This is a mandatory field. Surname *This is a mandatory field. Email *This is a mandatory field. Contact telephone number Extension (if applicable) *This is a mandatory field. Department / Ward *This is a mandatory field. Job Title *This is a mandatory field. Are you 65 or over? Please Select An Option YesNo *This is a mandatory field. Have you previously had any adverse reaction to an influenza vaccine, or any other vaccines? Please Select An Option YesNo *This is a mandatory field. Are you allergic to eggs? Please Select An Option YesNo * Spam Guard: What is the day after Thursday?
