This form is to say - NO THANK YOU - to Flu Vaccination

If you have received an invitation for a Flu Vaccination this year - then we would recommend that you come in to the surgery as it can be very important to help you stay well.

If however, you are really sure that you do not wish to have a Flu Vaccination then please can you fill in the form below.

The NHS requires every surgery to invite patients for various types of appointment several times which costs us a huge amount of money every year. It is really important to reply to all our requests if you really do not wish to have an appointment. Thank you for helping us by completing this form.

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* 1. First Name

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* 2. Last Name

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* 3. Date of Birth

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* 4. I have been recommended to have a Flu Vaccination - however I have decided that I do not wish to have one at Ball Tree.

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* 5. While you are here - please can you answer a couple questions about yourself that will help us keep your record up to date - this will really help us!

How many units of alcohol do you drink each week?

1 unit = a very small glass of wine or 1 shot or half a pint of lager
So if you have half a bottle of wine 2 x per week that would be about 10 - 12 units during the week
If you have 6 pints over a week - that is about 12 units for standard beer or 18 units for strong beers or lagers
For more information on units per week see NHS Choices (opens in a new window)

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* 6. Do you smoke at the moment?

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* 7. If you answered yes - currently a smoker above

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* 8. Do you have an email address?

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