Flu Nurse booking request form

Please complete all of the sections below and submit your form to book. You may find it helpful to read our FAQ’s at the bottom of the page prior to completing the form.
If you have any questions or want to book for multiple sites please contact the flu team on 0345 6090 115^{^}.

^* indicates a mandatory field.

Company details

Company Name*

Company address*

Post code*

Main contact details

First Name*

Surname*

Position in company*

Contact number*

Email address*

Invoice details

Tick if same as company details

Name

Address

Post code

Invoice notes:

Is this your first time booking flu vaccinations with us?*

No. of full days?* N.b We can administer approx 105 vaccinations per day

No. of half days?* N.b We can administer approx 53 vaccinations per day

Would you prefer a morning or afternoon session?*

What is your preferred clinic date?*

Total number of vaccines needed?*

Do you need pharmacy vouchers?*

If yes please tell us how many you need

Would you like to use our online booking system for your employees to book their timeslot?*

Bupa will contact you a day or two before your clinic to confirm the quantity of vaccines required.

Please confirm that all sites are suitable for the nurse and your employees on the day

The room should have:
• two chairs
• a small table
• a phone
• a waiting area with chairs outside
• JJ curtains or blinds on windows for privacy
• a large bin for waste paper

Please confirm that all sites are suitable for the nurse and your employees on the day

Yes
No

Is the room big enough to fit all of the above and space for employees to lie down if needed

Yes
No

The nurse will be introduced to a contact on the day who can help with any problems

Yes
No

The nurse will be introduced to the first aider on the day

Yes
No

Please tell us a bit about where the nurse will be working and if there are any potential risks

Will the nurse need any protective clothing on site

How did you hear about this service?*

Flu vaccinations FAQs >

^{^} We may record or monitor our calls.

We recognise that when you give us personal information (which includes health information) you’re trusting us to take good care of it. Please see our privacy policy for more information about how we collect, use and protect your data.

If you don’t want to receive marketing about Bupa products and services that we think are relevant to you, please contact us at optmeout@bupa.com.

Submit Reset