COVID-19 Boost Vaccination

To register your interest in being contacted for a Covid-19 boost Vaccine appointment in your preferred Healthwise Pharmacy, please complete the details below.

Please complete as many fields as possible below.

Gender (indicate):

Date of birth

(You will need to bring age identification with you to pharmacy at the time of your appointment.)

Indicate which vaccination cohort (if unsure please ask a member of the pharmacy team)

Residents and staff of long term care facilitiesFrontline Health Care WorkersPeople with a VERY HIGH risk medical conditionPeople with a HIGH risk underlying conditionKey workers essential to the vaccination programmePeople living or working in crowded settingsAllocation group based on age

Mothers Birth Surname:

Nationality:

If you don't have a PPS Number. Please explain why:

Personal Details:

GP Details

Not Registered with a GP

Section 1: Medical details.

1. Has this person ever had a serious allergic reaction (anaphylaxis) that needed medical treatment? i. after having a previous dose of the Moderna (Spikevax®) or any Pfizer/BioNTech (Comirnaty®) COVID-19 Vaccines, OR ii. to any of the vaccine ingredients, including polyethylene glycol known as PEG, OR iii. to Trometamol (an ingredient in a contrast dye used in MRI radiological studies)? If yes, they cannot get any Comirnaty® or Comirnaty® Children COVID-19 vaccine. But they may be able to have a different vaccine only if 12 years or older. They need to talk to their vaccination team and their GP. They may need specialist advice. If no, GO TO QUESTION 2. *

YesNo

2. Have they ever had a serious allergic reaction (anaphylaxis): i. after taking multiple different medications, with no reason known for the reaction. This may mean they are allergic to polyethylene glycol (PEG), OR ii. after having a vaccine or a medicine that contains polyethylene glycol (PEG), OR iii. for unexplained reasons? This may mean they are allergic to polyethylene glycol (PEG). If yes, they cannot get this vaccine, they may need specialist advice. Talk to the vaccination team. If no, GO TO QUESTION 3. *

YesNo

3. Have they ever had Mastocytosis (rare condition caused by an excess number of mast cells gathering in the body’s tissues) If yes, they can still get the vaccine, BUT, they should be observed for 30 minutes after they are vaccinated. Now go to next question. If no, GO TO QUESTION 4. *

YesNo

4. Have they had Myocarditis (inflammation of the heart muscle) or Pericarditis (inflammation of the
lining around the heart) after having a previous dose of COVID-19 vaccine?
If yes, answer question 4a. If no, GO TO QUESTION 5.. *

YesNo

4a. Since they had myocarditis or pericarditis after a previous dose of COVID-19 vaccine a specialist doctor must approve that they get this vaccine. Has their COVID-19 vaccination been approved by a specialist doctor? If yes, GO TO NEXT QUESTION. If no, they cannot get this vaccine. They should talk to their specialist doctor to check if they are suitable for this or another type of COVID-19 vaccine.*

YesNo

5. Have they had the Mpox or smallpox vaccine (Imvanex or Jynneos) in the last 4 weeks? If yes, they cannot get this vaccine today. They need to wait 4 weeks after getting these vaccines before getting a COVID-19 vaccine. If no, GO TO NEXT QUESTION. *

YesNo

6. Have they had a previous COVID-19 infection? If yes and they have been vaccinated against COVID-19 previously then they should wait at least 3 months since their last infection or vaccine before getting vaccinated. If yes and receiving a first ever dose of a COVID-19 vaccine, they should delay getting a vaccine until they have recovered from COVID-19 and it has been at least 4 weeks since they tested positive or developed symptoms. If no, GO TO NEXT QUESTION. *

YesNo

7. Does this person have a bleeding disorder or are they on anticoagulation therapy? If yes, they can still get a vaccine if they have a bleeding disorder or take anticoagulation medicines. But tell their vaccinator about their condition. If no, they are eligible. *

YesNo

Section 2: Question 8 for children and young people aged 5 to 17 years only!

8. Has this child or young person had multisystem inflammatory syndrome also called MIS-C (a rare syndrome usually treated in hospital) after a COVID-19 infection? If yes, please answer question 8a and 8b. If no GO TO NEXT SECTION. *

YesNo

8a. Has this child or young person clinically recovered from MIS-C?
If yes, GO TO QUESTION 8b.
If no, this child or young person cannot be vaccinated today. *

YesNo

8b. Has it been over 90 days since this child or young person was diagnosed with MIS-C?
If yes, GO TO NEXT QUESTION. If no, this child or young person cannot be vaccinated today. *

YesNo

Section 3: Question 9 Only complete this section if you are getting a second or third dose of a COVID-19 vaccine after your first dose because you have a weak immune system (immunocompromise)!

9. Are you receiving a second dose of a COVID-19 vaccine 4 weeks after your first dose because you have a weak immune system? If yes, GO TO QUESTION 9a. If no, GO TO QUESTION 10. *

YesNo

9a. Has it been at least 4 weeks since their 1st dose of the vaccine?
If yes, GO TO QUESTION 9b. If no, they should wait at least 4 weeks since their last dose. *

YesNo

9b. Have they been diagnosed with COVID-19 infection since their first dose of COVID-19 vaccine?
If yes, they should wait at least 4 weeks from when they tested positive or developed symptoms before
getting their second vaccine. If no, GO TO NEXT QUESTION *

YesNo

10. Are they receiving a third dose of a COVID-19 vaccine after their second dose on the advice of a
specialist doctor?
If yes, go to Question 10a. If no, GO TO NEXT SECTION. *

YesNo

10a. If yes, has it been at least 4 weeks since their last COVID-19 vaccine dose?
If yes, go to question 10b.
If no, they should wait at least 4 weeks since the last COVID-19 vaccine. *

YesNo

10b. If they are receiving a third dose of a COVID-19 vaccine after their second dose because they have
a weak immune system, have they had COVID-19 infection since their second COVID-19 vaccine
dose?
If yes, the vaccinator will advise if they need a vaccine based on current NIAC advice.
If no, GO TO NEXT SECTION. *

YesNo

Section 4: Only complete the following questions if the person is pregnant

11. Are they pregnant? If yes, complete questions 11a, 11b and 11c depending on their situation. If no, they are eligible for the booster today. *

YesNo

11a. Have they already had a COVID-19 vaccine in this pregnancy?
If yes, they should be informed that usually in pregnancy, only one dose is offered. However, if they are
pregnant and immunocompromised, a second dose of the vaccine may be considered if it has been more
that 6 months since their last vaccine or infection. They should speak to their healthcare provider.
If no, GO TO QUESTION 11b. *

YesNo

11b. Have they had COVID-19 infection or a COVID-19 vaccine in the last 6 months?
If yes, they should wait at least 6 months from their last COVID-19 infection or COVID-19 vaccine dose to
get vaccinated. *

YesNo

Please note that the interval between last infection or last vaccination is different in pregnancy. If eligible, a COVID-19
vaccine can be given at any time in pregnancy but ideally should be given between 20 and 34 weeks of pregnancy.

Consent

I understand:

The nature of the treatment.
The risks of Covid-19.
The benefits and risks of immunisation.
The possible side effects of vaccination, when they might occur and how they should be treated.

I have been given an opportunity to ask questions and raise any concerns.

Please select your local pharmacy

I agree to the Healthwise Pharmacies Privacy Policy. (Please note: If you do not agree, you may fill out a vaccination registration form in store.)

What is my COVID-19 vaccination course?

Autumn 2025 Covid Booster Doses:

Bookings are now open for Autumn 2025 Covid booster doses.

You will be offered a booster dose if you are:

age 60 and older
age 18 to 59 living in a long-term care facility
age 6 months to 59 years with a weak immune system
age 6 months to 59 years with a condition that puts you at high risk of serious illness from COVID-19
a healthcare worker
pregnant – booster doses needed during pregnancy

If you’re age 18 to 59 and not in one of the groups above, you can still request a vaccine. Talk to your GP or pharmacist about your reasons for wanting a booster.

You can get your COVID-19 booster and flu vaccine at the same time.