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Covid-19 vaccination appointment request

COVID-19 Vaccination Appointment Request

Section

Is this your up to date telephone number? *
Has your GP Practice invited you to book your COVID-19 vaccination? *

You cannot submit this form unless you have been invited by your GP Practice to book your COVID-19 vaccination.

Eligibility

Please select the relevant age category: *

Have you previously had a serious allergic reaction? *
Do you carry an EpiPen (adrenaline auto injector)? *
Have you taken part in any Coronavirus vaccination trials? *
Have you had Coronavirus in the last 4 weeks? *
Have you received any vaccination in the last 7 days? *
Are you currently taking anticoagulant medication called Warfarin? *
Is your INR up to date and within range? *

You cannot continue with this appointment request. Please contact the GP Practice via the Request an appointment with a Nurse or Healthcare Assistant form to check your INR.

Please select if you’d prefer a certain time slot:
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