• 01223353015
  • 123 Milton Road, Cambridge, CB4 1XE

Private Flu Jab 2024-2025 Questionnaire

This form can be completed on the day of your appointment.

Private Flu Jab 2024-2025 Questionnaire
Name
Name
First
Last
Address
Address
City
County
Post Code
Do you have any allergies? (Egg, latex or other)
Have you ever had a severe allergic reaction, or a reaction to a vaccination in the past?
Do you feel unwell or have a temperature today?
* Please let us know if you are unwell on the day of your appointment
Do you feel unwell or have a temperature today?
Are you pregnant or breast feeding?
Do you have asthma or lung problems?
Do you have asthma or lung problems?
Do you have asthma or lung problems?
Do you have epilepsy?
Do you have a neurological condition?
Do you have diabetes?
Consent
Flu Jab Service Reminder