Information:

This form is for NHS professionals and businesses, not for the general public. If you are looking for our public facing hospital services, please visit our service finder.

I, the undersigned, give my consent for the Occupational Health Department at Liverpool University Hospitals NHS Foundation Trust to release my immunisation details to the following person / organisation.

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Required
I will collect this from the Occupational Health Wellbeing Centre on the Aintree site. Please ring me when this is ready for collection
Please email this to me (this will be sent unencrypted to the email address you have provided)
Please send this out in the post to me or directly to my new Occupational Health Dept
Your address
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