The Health & Social Care Portfolio is attempting to secure a supply of the influenza ('flu) vaccine and wants to know whether you are interested in receiving it later this year. In order for the correct number of vaccines to be ordered, please register your interest by completing this form.

You may also complete this form on behalf of someone else who is interested in receiving the vaccine.

The influenza vaccine is only offered to some groups of people - you can tell us if you belong to one of these groups by completing this form. Most healthy adults under the age of 65 years do not need to receive the vaccine.

Children and young people aged 16 years or younger, pregnant women, people living in a residential or nursing home, and frontline health and social care workers do not need to register their interest - enough vaccines will be ordered for everyone in these groups.

You can also register your interest by calling the Health Promotion team on 25949. If you have any questions about the influenza vaccine, please email healthpromotion@sainthelena.gov.sh.

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1. Name (Required.)

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2. Date of Birth (Required.)

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3. Home address (Required.)

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4. Phone number(s) (Required.)

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5. Select any circumstances that apply: (Required.)

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