Leach Heath Medical Centre
Register for a free flu jab
Please complete the form below to register for a free flu jab this winter.
(1/2 steps)
Forename(s)
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Surname
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Date of birth (For example, 31 3 1980)
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Email address
Please tick why you are eligible for a free flu vaccination
I am a carer
I am aged 65 or over
I am pregnant
I am a child aged 2 or 3 on 31ˢᵗ August 2021
I live with someone who's at high risk from Coronavirus (on the NHS shielded patient list)
I am under 65 years of age and I have a long term condition listed below
• a heart problem
• a chest complaint or breathing difficulties, including bronchitis, emphysema or severe asthma
• a kidney disease
• lowered immunity due to disease or treatment (such as steroid medication or cancer treatment)
• liver disease
• had a stroke or a transient ischaemic attack (TIA)
• diabetes
• a neurological condition, eg multiple sclerosis (MS), cerebral palsy
• a learning disability
• a problem with your spleen, eg sickle cell disease, or you have had your spleen removed
• are seriously overweight (BMI of 40 and above)
I am aged 50 to 64 with none of the listed conditions, but would like a flu vaccination if they become available later in the year
I am eligible for a flu vaccination this year for a reason not listed
If reason is not stated please state reason
I consent to being contacted by the details given above. I agree to the
privacy policy.
*
Yes
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