Have you ever had any of the following vaccinations / tablets and if so, when?
I have given full and accurate information regarding my medical and vaccination history and travel plans. I have been advised to have the vaccines and other items indicated with a YES tick in the treatment and advice schedule overleaf.
I understand the health risk and advice given and consent to vaccination and the payment of fees for non-NHS vaccines
Or (delete as applicable)
I understand the health risks and advice given and consent to vaccination and the payment of fees for non-NHS vaccines except for ………………………………………
I understand and accept the risk of disease in unvaccinated.
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be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key known only to the GP practice and is
accessed over a secure connection by nominated Practice staff. Our practice has a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to
Alcester Health Centre
Fields Park Drive, Alcester Warks, Warks, B49 6QR.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.