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Influenza Vaccine History
Full Name
Date of Birth
Email
Home Tel
Work Tel
Mobile Number
Home Address
Street Address
Address Line 2
City
County
Postal Code
GP Address
Street Address
Address Line 2
City
County
Postal Code
Influenza Vaccine History
Have you received the influenza vaccine?
Yes
No
Consent is a process rather than a one off decision, for consent to be valid, it must be voluntary and informed. You have the right to withdraw your consent at any stage of the process, either verbally or in writing.
Do you consent to this declaration form being processed by Total Assist as per our data protection policy?
Yes
no
Do you consent to this declaration being shared with the trust here you will be placed in lined with their data protection policy?
Yes
no
Declaration
I declare that the answers to the above questions are true and complete to the best of my knowledge and belief.
Applicant/Candidate's Email
Date
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