IntraHealth NHS Immunisations

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NO, I DO NOT consent for my child to receive the Flu immunisation

NO consent form for Unknown School (from September 2024)

Child's Details

please tell us about the child to be vaccinated

Firstname *

Please enter a value

Surname *

Please enter a value

Known As

Date of Birth *

Please enter a value

Gender

Male

Female

Other

Please choose gender

Ethnicity *

Please enter a value

School Year Group (from September 2024) *

Please enter a value

NHS Number

Please enter a value

Enter postcode and search for address

Address *

Please enter a value

Town/City *

Please enter a value

Postcode *

Please enter a value

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GP Details

please tell us about the your child's GP

GP Name

GP Address

Town

Postcode

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Your Details

As Parent/Guardian we need the following information from yourself

Firstname *

Surname *

It is important to give a valid phone and email to ensure your child receives the best care.

Home / Daytime Telephone Number *

Daytime Telephone Confirm *

Mobile Telephone Number (for sms text confirmation) *

Confirm Mobile Telephone Number *

E-mail Address *

Confirm E-mail Address *

Can we contact you about the service?

Yes

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Confirmation

Please complete the final step to show you understand and DO NOT consent to the immunisation

I do not wish my child to receive the FLU immunisation because

Confirmation

Please confirm you DO NOT consent for your child to have the Flu immunisation?

I DO NOT CONSENT for my child to receive the FLU immunisation

Parent / guardian (with parental responsibility) *

Relationship to child *

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