AAH Non Healthwatch Flu Sign Up Form

AAH non healthwatch
Flu Vaccination Sign Up Form

AAH Branch number: *

(eg. 703M)

AAH Account Number: *

8 digits followed by a letter

Pharmacy Name: *

Pharmacy Address: *

Post Code: *

Telephone Number: *

Email Address: *

Venue:
PLEASE NOTE customers who are rebooking with AAH can benefit from a fast-track half day training. Select from either AM or PM sessions where available. New customers are required to undertake a full day training.
Please make you choice below.

Lead Pharmacist :

Extra Pharmacist:

Service Fees: *

Lead Pharmacist (Re-booking) £299

Extra Pharmacist (Re-booking) £170

Lead Pharmacist (New) £347

Extra Pharmacist (New) £199

Terms & Conditions: *

I confirm that I am a non Healthwatch member and accept the terms and conditions

By selecting this option you are accepting that you will not be able to administer flu vaccines until you have successfully completed the training and received all counter signed certificates. You slso understand that you are committing to receiving 20 flu vaccines from AAH during the 2010 season and that charges for this service, including a non-refundable £50 booking fee, will be applied to your AAH account.

AAH non healthwatch Flu Vaccination Sign Up Form

AAH non healthwatch
Flu Vaccination Sign Up Form