Eyemouth Medical Vaccination Opt-Out 

Patients who wish to opt out of any of our vaccination programmes can do so by filling out their information below which will be automatically submitted to the practice. Further information be found here


Patient Name

Patient Date Of Birth

Please note that dates MUST be in the format of DD/MM/YYYY ie: 21/02/1950.

Daytime Contact Number

Patient Post Code

Email Address

Opt-Out Choice

Please select one or more of the vaccinations below that you would like to opt out from:

PneumococcalInfluenzaShingles

I confirm that I wish to decline the above vaccine(s) and understand that this is against medication advice: