Flu Clinic 31/10/2020 Form for Completion

For Flu clinic tomorrow 31st October 2020

PLEASE COULD YOU PRINT & COMPLETE THIS FORM AND HAND TO THE RECEPTIONIST WHEN YOU CHECK IN. IT IS IMPORTANT FOR US TO HAVE UP TO DATE CONTACT INFORMATION and COLLECT ANNUAL UPDATES

Patient name: ______________________________________________________

Date of birth: _____________________________________________

Home telephone number: _________________________________

Mobile telephone number: _________________________________

Are you happy to be contacted by email (please circle)    YES / NO

Email address: ______________________________________________________

Due to COVID-19 Restrictions where possible we wish to send prescriptions directly to a nominated pharmacy. If you currently come to the surgery to pick up your prescription please could you let us know where you would like your prescriptions to be sent. Please circle your preferred pharmacy.

West Street Pharmacy    Asda   
Acorn Chemist    Boots   
Heringtons     Tesco   
Mayfield     Lloyds (Sainsbury’s) 
Jhoots (High Street)    Lloyds (High Street)  
Langdale     Avicenna   

Other ________________________

Smoking status? (Please circle)  Smoker / non-smoker

Signature: _______________________ Date: ______________________