Please note there is a charge for several of the injections, please bring cash or cheque for your appointment.
(if not applicable please leave empty)
For discussion when risk assesment is performed within your appointment: I have no reason to think that I might be pregnant. I have recieved information on the risks and benefits of the vaccines recommended and have had the opportunity to ask questi
Information submitted through secure forms is used only for the purposes of processing your request. We may
be in touch with you in relation to the information submitted.
All Information submitted through secure forms is secured with a private key and is accessed over a secure
connection by nominated staff. We have a strict confidentiality policy.
This information is not shared with any third party organisations.
This information is retained for up to 28 days.
I consent to my information being used for the purposes described above and wish to submit this online form to
Great James Street Health Centre, Great James Street, Derry, BT48 7DH.
Should you have any concerns about sending your personal details using the web,
please use one of the alternative methods offered by our organisation.