Flu Clinic Request 2022 Flu Clinic Request 2022/23 This form will allow patients to request a Flu Clinic appointment. "*" indicates required fields I am a patient at Gleadless Medical Centre* Yes No This form is only for use by patients registered at Gleadless Medical Centre. If you live within our catchment, we are accepting new registrations. See our web site for details.Name* First Last Date of Birth* Day Month Year Email Optional Flu ClinicOur flu clinics are currently full: further clinics will be added once vaccinations have been secured. Optional Optional Optional Optional Optional Optional Optional Decline VaccinationsIf you wish to decline the Flu or Covid vaccinations, then please click the appropriate boxes and we will not send further reminders. I do NOT wish to have the FLU vaccine Optional I do NOT wish to have the COVID vaccine Optional Spouse/PartnerIf anyone living at your address has also received an invitation, please add their name here and we will try to book you appointments at the same time. They will not need to respond to the text invitation. Please do not add anyone who has not been invited. First Optional Last Optional Date of birth* Day Month Year Comments OptionalThis field is for validation purposes and should be left unchanged.