WINCHMORE HILL PRACTICE & PARK LODGE MEDICAL CENTRE
Appointment Request Form - Children's Flu Clinic (ages 2 & 3 years)

REGISTER FOR APPOINTMENTS FOR CHILDREN AGED 2-3 YEARS

Please note that this years Flu Vaccination Campaign is being delivered differently. To observe strict guidelines to keep you safe, including social distancing and infection control, children's flu clinic will be delivered from our FLU STATION, located at the back end of our practice car park.

PLEASE BRING YOUR CHILD IN THEIR BUGGY/STROLLER FOR THEIR APPOINTMENT.

Question Title

* 1. Surname

Question Title

* 2. Forename(s)

Question Title

* 3. Date of birth

Date / Time

Date

WINCHMORE HILL PRACTICE & PARK LODGE MEDICAL CENTRE
Appointment Request Form - Children's Flu Clinic (ages 2 & 3 years)

REGISTER FOR APPOINTMENTS FOR CHILDREN AGED 2-3 YEARS

Question Title

* 1. Surname

Question Title

* 2. Forename(s)

Question Title

* 3. Date of birth

Question Title

* 4. Contact number (landline)

Question Title

* 5. Contact number (mobile)

WINCHMORE HILL PRACTICE & PARK LODGE MEDICAL CENTRE Appointment Request Form - Children's Flu Clinic (ages 2 & 3 years)

REGISTER FOR APPOINTMENTS FOR CHILDREN AGED 2-3 YEARS

Question Title

* 1. Surname

Question Title

* 2. Forename(s)

Question Title

* 3. Date of birth

Question Title

* 4. Contact number (landline)

Question Title

* 5. Contact number (mobile)

WINCHMORE HILL PRACTICE & PARK LODGE MEDICAL CENTRE
Appointment Request Form - Children's Flu Clinic (ages 2 & 3 years)