Flu Vaccination Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.LayoutForename *Surname *Date Of Birth *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email Address *EmailConfirm EmailMobile Phone Number *Age (in Years) *Schools Name *Schools Postcode *URN Number *Are you in an eligible group to receive a free flu vaccination via the NHS? Categories include: *YesNo Aged 65 or over Have certain long-term health conditions Are pregnant Live in a care home Are the main carer for an older or disabled person Or receive a carer's allowance, live with someone who has a weakened immune system. NHS Number (if Known) GP NameGP AddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodePlease provide the location of the preferred Boots store you wish to use. *You can check to see where your nearest available store is here Does this store offer flu vaccinations? YesNoAre there suitable times available to book an appointment?Submit
