Flu Appointment request

Flu Vaccination request

Patient’s Name

First

Patient’s Last Name

Last

Date of Birth

Phone

Flu Clinics at Valentine Health Partnership

For patients 65 years and over clinics start from 01/10/2022

For patients, 18 years and over with certain medical conditions ( At Risk group) clinics start from 15/10/2022

For patients Under 18 years old, clinics start from 15/11/22

For patients 50 to 64 years old, not in a clinical at-risk group, clinics to be advised ( Please await letter)

I would like to request a FLU appointment for:

For patients 65 years and over

For patients, 18 years and over with certain medical conditions ( At Risk group)

For patients Under 18 years old

For patients 50 to 64 years old, not in a clinical at-risk group

carers / in receipt of carer’s allowance / or main carer of an older or disabled person

If you are human, leave this field blank.

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