Register for a Free Flu Jab Form

Complete the form below to register for a free flu jab this winter (Stage 1 of 2)

Full Name

Date of Birth (For example, 31 3 1980)

Contact Number (Mobile)

Email Address

Address

Select why you are eligible for a free flu vaccination (Optional)

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, state the reason (Optional)

I consent to being contacted via the details given above. I agree to the privacy policy.

Yes