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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):

    If you are a female, please answer below:

    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)

    Mothers Birth Surname:

    Nationality:

    Ethnicity:

    PPS Number:

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

    Personal Details:

    GP Details

    Question 5 for 5 to 17 Years Old ony!

    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./li>

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

    Please select your local pharmacy

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