Request a Flu Vaccine - Pontardawe Primary Care Centre

If you are eligible for the vaccines, but do not have a My Health Online account, you can complete the form to request an appointment.

We will contact you with confirmation within 48 hours

Eligibility for the vaccine

Is this request submitted for yourself or for someone you care for? Please note the practice must have received written consent to discuss any patient medical needs who are over the age of 18+

On behalf of myself
On behalf of my child
On behalf of someone I care for and confirm the practice already has written consent for this.

Name of patient

Bate of Birth

I confirm I am eligible for the vaccination

Yes

Your preferred contact number