AAH Healthwatch Flu Sign Up Form

AAH Healthwatch
Flu Vaccination Service Sign Up Form

AAH Branch number: *

e.g.703M

AAH Account Number: *

12345678M

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.

Lead Pharmacist: *

Extra Pharmacist: *

Service Fees: *

Terms & Conditions: *

I confirm that I am a 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 Healthwatch Flu Vaccination Service Sign Up Form

AAH Healthwatch
Flu Vaccination Service Sign Up Form