Influenza form

If you don't have a medical indication but would like to receive the influenza vaccination, please fill out this form and present it to our pharmacy staff.  AS soon as they have approved your request, our nurses will administer the vaccine. The cost will be € 30 in total.

By undersigning this form I declare that

Please print out this form by clicking the print option in your browser (or click  Ctrl +P), place your signature  and present it to our pharmacy staff.

 * immunosuppressants amongst others: glucocorticosteroids like prednisolone; anti-cancer  drugs (cytostatics)

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