I do not want my Flu Vaccine 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 DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec *This is a mandatory field. Department / Ward *This is a mandatory field. Job Title Are you 65 or over? Please Select An Option YesNo Have you had the flu vaccine elsewhere? Please Select An Option NoYes - GPYes - Pharmacy I don’t want to receive the flu vaccine because Please Select An Option I’m concerned about possible side effects I don’t like needles I don’t think I’ll get the fluI don’t think the vaccine is effectiveI don’t believe that the evidence for being vaccinated is beneficialIt was difficult/inconvenient to get to the place where vaccinations were being offeredThe times when the vaccination were being offered were not convenient If none of the above reasons, please tell us why? * Spam Guard: Do fish swim in the sea or sky?
