Shingles Decline

If you have been contacted by the Practice or are eligible to receive a free Shingles vaccination for this year’s Shingles campaign (eligibility below) and wish to decline please complete the following information. If you change your mind during the Shingles campaign, you can still have the vaccine and can arrange this by contacting the Practice:

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Email Address: *

Any responses we send will go to this email address.

Phone Number:

I wish to decline

I wish to decline as I have been vaccinated elsewhere

Please specify where vaccination was given:

Please specify date given:

Please follow the link below to check if you are eligible for the shingles vaccine, for information on who should not have the Shingles vaccine.
www.nhs.uk

Tell us whether you accept cookies

Shingles Decline

Vacancies