Vaccine Enquiry Form

If you are a Blackthorn Health Centre patient, please use the form below for your Flu and / or COVID-19 vaccine enquiries only.

(due to patient confidentiality, unless we have a record of a patient's carer, we require the patient with the enquiry to complete this form.)

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Decline Vaccination(s)

By completing this section, you acknowledge that you will be declining the named vaccine(s).

Please note certain vaccines, including the flu vaccine, are annual invitations and therefore you may be asked again regarding this vaccination next year.

 

Please find below the NHS definition of an immunosuppressed individual:

  • Immunosuppression due to disease or treatment, including patients undergoing chemotherapy leading to immunosuppression, patients undergoing radical radiotherapy, solid organ transplant recipients, bone marrow or stem cell transplant recipients, HIV infection at all stages, multiple myeloma or genetic disorders affecting the immune system (e.g. IRAK-4, NEMO, complement disorder, SCID).
  • Individuals who are receiving immunosuppressive or immunomodulating biological therapy including, but not limited to, anti-TNF, alemtuzumab, ofatumumab, rituximab, patients receiving protein kinase inhibitors or PARP inhibitors, and individuals treated with steroid-sparing agents such as cyclophosphamide and mycophenolate mofetil.
  • Individuals treated with or likely to be treated with systemic steroids for more than a month at a dose equivalent to prednisolone at 20mg or more per day for adults.
  • Anyone with a history of haematological malignancy, including leukaemia, lymphoma, and myeloma.
  • Those who require long-term immunosuppressive treatment for conditions including, but not limited to, systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, scleroderma and psoriasis.

 

If you believe an individual you live with falls into one of the above categories, please provide us with further information via the form below so we can review this further with one of our clinicians.

 

 
 

Housebound Patients

A patient will be deemed to be housebound when they are unable to leave their home environment through physical and / or psychological illness.   

An individual will not be eligible for a home visit if they are able to leave their home environment on their own or with minimal assistance to visit public or social recreational public services, (including shopping).

In addition, an individual would not be classed as housebound as a result of transport difficulties. You can contact one of our Good Neighbours Network to arrange transportation to and from medical appointments. The local Good Neighbours Network contact details are as follows:

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
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