Vaccination request

Book a Vaccination

Please note, a form must be filled in for each patient response. Please enter the child’s details if you are responding on behalf of your child.

Which vaccine invite are you responding to? *

Childhood vaccinations – Given to children aged 0-5 years. More information can be found by visting Childhood Vaccinations: Essential Information.

Influenza vaccination (flu vaccine) – Given to patients that are at greater risk of complications from the influenza virus. More information can be found at NHS: Flu Vaccine

Shingles vaccination – Given to patients in their 70s to prevent shingles. More information can be found at NHS: Who should have the shingles vaccine?

Whooping cough (pertussis) vaccination – Given to pregnant women to protect new born babies from whooping cough. More information can be found at NHS: Whooping cough vaccination in pregnancy

Pneumococcal (pneumonia) vaccination – Given to older patients and those at greater risk of pneumonia infections. More information can be found at NHS: Who should have the pneumococcal vaccine?

Please let us know whether you would like to have the vaccine, ask for more information or decline the offer: *

I would like to be contacted to book my appointment for the above vaccination that I have been invited for (the surgery will call you).

I would like more information about the vaccination that I have been invited for (the surgery will call you to answer any questions you may have).

I would like to decline the above vaccination that I have/my child has been invited for by the surgery. I understand the risk of not being vaccinated/my child not being vaccinated (please note you may still be contacted in the future in case you change your mind).

Do you have a specific date, day of the week or time of day that you would prefer for an appointment?

I confirm that I am a patient at Grovelands Medical Centre, London.

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