Request an Appointment for Flu Vaccination

Complete this form to request an appointment for flu vaccination in your chosen Haven Pharmacy. The information requested below will allow the pharmacist to quickly assess the safety and suitability of flu vaccination for each person. This also means the pharmacist can determine which vaccine is most suitable, and whether you can avail of free vaccination. Providing this information to the pharmacy in advance will also limit the amount of time you need to spend in the pharmacy, keeping you and our pharmacy teams safe.

More information on Pharmacy Flu Vaccination is available here.

Please note: completing this form and submitting a request for booking does not guarantee an appointment. The pharmacy will contact you as soon as possible to confirm if an appointment is available. You will receive a confirmation email after you send your completed form – please check your spam/junk folder if you do not receive it.

All fields or questions marked with * are required. Failure to complete all required information will lead to delays.
  • Complete this form in full to submit a request to your chosen Haven Pharmacy for a Flu Vaccination appointment
  • Personal Details for the Person Requesting Vaccination
  • The following medical questions will allow the pharmacist to make sure that vaccination is safe and suitable
  • Some people may be eligible for free Flu Vaccination. Please select Yes if any of the following applies for the person requesting vaccination
  • Privacy Notice: By completing and sending this form, you agree that your information will be sent to your chosen Haven Pharmacy, who will use the details you provided to contact you and organise an appointment if available. Your information is not stored on this website. Click SEND to submit this form to your chosen pharmacy.