I do not want my Flu Vaccine

Note: Questions marked by * are mandatory

*This is a mandatory field. First name

*This is a mandatory field. Surname

*This is a mandatory field. Date of birth

*This is a mandatory field. Department / Ward

*This is a mandatory field. Job Title

Are you 65 or over?

Have you had the flu vaccine elsewhere?

I don’t want to receive the flu vaccine because

If none of the above reasons, please tell us why?

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King George Hospital Barley Lane Goodmayes Greater London IG3 8YB	Queen's Hospital Rom Valley Way Romford Greater London RM7 0AG
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