COVID-19 Vaccine Booking Form Setup

COVID-19 Vaccine Booking Form Setup
Existing Customer

yesno
Pharmacy Name*
Phone Number for Vaccination/Booking Queries*

Area CodePhone Number
Email Address for Waitlist & Booking Notifications*
mail@pharmacy.com
Staff Member Login

These are the staff members you'd like to be able to log in and manage appointments.

Please provide an email address for each staff member you'd like to have access. We'll send them out an invitation with instructions to set their account up.
Staff Member Emails*
To access appointments, you log into a cloud based pharmacy portal on a web browser. This uses a system called 2-factor authentication to help secure patient data under GDPR (similar system to the banks). This means you login by entering something you know which is your password and something you have which is your mobile phone or a USB security key.

Using a phone means an SMS text containing a 6 digit code gets sent to your phone number when logging in. We set this method up by default.

Using a USB security key means you press a button on the USB security key, that is plugged into a computer. Useful if you have locums or don't allow mobile phones in the pharmacy. If you select USB security key, we will email you set up instructions.
Preferred Method for 2-factor Authentication

Appointment Settings
You have the option of choosing default text for both the information and consent that is displayed to the patient when they are registering/booking, or you can specify your own text instead.
Time required for Covid-19 Vaccination*
Enter the title or name of the vaccination*
Enter a sub-title or short description of the vaccination:
How would you like to send the appointment confirmation and reminders to your patients?

Email onlySMS text* onlySMS text* and email
* Charges apply for SMS texts. Details on our website.
Select which messages you want to send to patients:

Booking confirmation (within 10 minutes of the booking)Appointment reminder (1 hour before the appointment)Appointment reminder (1 day before the appointment)

Information Text
Default Text
What is COVID-19?
COVID-19 is an illness that can affect your lungs and airways, and sometimes other parts of your body. It’s caused by a virus called coronavirus.

COVID-19 is highly infectious. It spreads through the air through droplets produced when people cough or sneeze, or when they touch surfaces where the droplets have landed and then touch their eyes, nose or mouth.

COVID-19 can cause serious illness, hospitalisation and even death.

Older people and people with certain health conditions have a higher risk of getting seriously ill if they get COVID-19.

What is the COVID-19 vaccine?
A vaccine is a substance that should improve immunity (protection) to a particular disease. The COVID-19 vaccine will offer you protection from COVID-19. If people are vaccinated, it should also reduce the numbers who become seriously ill or even die from COVID-19 in our community.

Vaccines teach your immune system how to protect you from diseases. It is much safer for your immune system to learn how to protect you through vaccination than by getting COVID-19.

Who should get the vaccine?
While it is up to you to decide to get the vaccine, the HSE, the World Health Organization and the Department of Health strongly recommend that you do so as soon as it is offered to you.

Are COVID-19 vaccines safe?
Covid-19 vaccines used in Ireland are safe. All vaccines used in the Republic of Ireland must be approved by the European Medicines Agency (EMA). The EMA only approves vaccines once they are satisfied that they are safe and effective. Because COVID-19 has caused a crisis all around the world, lots of work is being done by experts in many countries. These experts have worked together to develop safe vaccines as quickly as possible. But COVID-19 vaccines that are used in Ireland and approved by the EMA must still go through the same safety and effectiveness assessments that all other vaccines and medicines go through before they are approved. In Ireland, the Health Products Regulatory Authority (HPRA) works to make sure that side effects that people get are reported and followed up.

Are there side effects from COVID-19 vaccines?
Like all medicines, vaccines can have side effects. The side effects are mostly mild or moderate and include things like having a sore arm or itching in the part where the injection was given, feeling tired, feeling sick, swollen lymph glands in the arm where the vaccine was given, body chills or feeling like you have a fever. Some people don’t get any side effects at all. More rarely, people experience sleeplessness, or temporary weakness in their face muscles. The side effects from a COVID-19 vaccine are similar to the side effects that you can get from other vaccines. We know this from looking at the results of clinical trials, and from the reports from the millions of people around the world who have already been vaccinated. We know that serious side effects to vaccines, like an allergic reaction, are extremely rare. As more people in Ireland and around the world get this vaccine, the HSE will update our website with any new information. You can report any side effects you experience to the HPRA. The link is below.

GETTING THE VACCINE AND YOUR APPOINTMENT

COVID-19 HEALTH SCREEN:
Do not attend your appointment if
• you have any current symptoms of Covid 19 or
• have been diagnosed with Covid 19 in the last 4 weeks or
• have been told you are a close contact of someone with Covid 19 or
• have been told you should isolate or
• have recently returned from foreign travel

WHEN YOU SHOULD NOT GET A COVID VACCINE:
• Following an anaphylactic reaction to a first dose of a Covid Vaccine
• If you are allergic to any of the ingredients contained in the vaccine as listed further below

APPOINTMENT TIMES:
• You should allow at least 30 minutes for your vaccination appointment. After getting the vaccine, you will be under observation for 15 minutes.
• Please be on time but do not arrive to the pharmacy more than 5 minutes before your appointment
• You will be sent a reminder prior to your appointment
• If you need to cancel or reschedule your appointment please contact the pharmacy as soon as you can
• Adults should arrive for their vaccination unaccompanied where possible

ON THE DAY:
• Please where a loose fitting top so that your upper arm is easily accessible
• Bring your phone, photo ID and a face covering
• If this is your second vaccination dose please bring your vaccination record card

VACCINE INFORMATION LEAFLETS:
Please read the relevant information about your assigned vaccine prior to your appointment. Leaflets will also be available at the pharmacy when you arrive for your vaccination.

[• Johnson & Johnson Vaccine leaflet](https://www.hse.ie/eng/services/news/newsfeatures/covid19-updates/covid-19-vaccine-materials/important-information-about-the-covid-19-vaccine-janssen.pdf)

[• PfizerBioNTech Vaccine leaflet](https://www.hse.ie/eng/services/news/newsfeatures/covid19-updates/covid-19-vaccine-materials/covid-19-vaccine-information-leaflet-after-18-jan.pdf)

VACCINE EXCIPIENT LIST:
Johnson & Johnson Vaccine: 2- hydroxypropyl-β-cyclodextrin (HBCD),Citric acid monohydrate, Ethanol, Hydrochloric acid,Polysorbate-80, Sodium chloride, Sodium hydroxide Trisodium citrate dihydrate, Water for injections

PfizerBioNTech Vaccine: polyethylene glycol/macrogol (PEG) as part of ALC-0159, ALC-0315 = (4-hydroxybutyl) azanediyl)bis (hexane-6,1-diyl)bis(2-hexyldecanoate),, ALC-0159 = 2-[(polyethylene glycol)-2000]-N,N-ditetradecylacetamide,, 1,2-Distearoyl-sn-glycero-3-phosphocholine, cholesterol, potassium chloride, potassium dihydrogen phosphate, sodium chloride, disodium hydrogen phosphate dihydrate, sucrose, water for injections.

FURTHER INFORMATION:
For more up-to-date Covid related information please follow the links below or contact the HSE on 1850 24 1850.

[Health Products Regulatory Authority](https://www.hpra.ie/)

[HSE Immunisation website](https://www.hse.ie/eng/health/immunisation/hcpinfo/covid19vaccineinfo4hps)
Would you like to modify the default information text for "Covid-19 Vaccination"? If you select Yes, your edited text will replace the provided information text.

YesNo
Please enter your custom Information Text for "Covid-19 Vaccination" below
Custom Information Content for "Covid-19 Vaccination"
#What is COVID-19? COVID-19 is an illness that can affect your lungs and airways, and sometimes other parts of your body. It’s caused by a virus called coronavirus. COVID-19 is highly infectious. It spreads through the air through droplets produced when people cough or sneeze, or when they touch surfaces where the droplets have landed and then touch their eyes, nose or mouth. COVID-19 can cause serious illness, hospitalisation and even death. Older people and people with certain health conditions have a higher risk of getting seriously ill if they get COVID-19. #What is the COVID-19 vaccine? A vaccine is a substance that should improve immunity (protection) to a particular disease. The COVID-19 vaccine will offer you protection from COVID-19. If people are vaccinated, it should also reduce the numbers who become seriously ill or even die from COVID-19 in our community. Vaccines teach your immune system how to protect you from diseases. It is much safer for your immune system to learn how to protect you through vaccination than by getting COVID-19. #Who should get the vaccine? While it is up to you to decide to get the vaccine, the HSE, the World Health Organization and the Department of Health strongly recommend that you do so as soon as it is offered to you. #Are COVID-19 vaccines safe? Covid-19 vaccines used in Ireland are safe. All vaccines used in the Republic of Ireland must be approved by the European Medicines Agency (EMA). The EMA only approves vaccines once they are satisfied that they are safe and effective. Because COVID-19 has caused a crisis all around the world, lots of work is being done by experts in many countries. These experts have worked together to develop safe vaccines as quickly as possible. But COVID-19 vaccines that are used in Ireland and approved by the EMA must still go through the same safety and effectiveness assessments that all other vaccines and medicines go through before they are approved. In Ireland, the Health Products Regulatory Authority (HPRA) works to make sure that side effects that people get are reported and followed up. # Are there side effects from COVID-19 vaccines? Like all medicines, vaccines can have side effects. The side effects are mostly mild or moderate and include things like having a sore arm or itching in the part where the injection was given, feeling tired, feeling sick, swollen lymph glands in the arm where the vaccine was given, body chills or feeling like you have a fever. Some people don’t get any side effects at all. More rarely, people experience sleeplessness, or temporary weakness in their face muscles. The side effects from a COVID-19 vaccine are similar to the side effects that you can get from other vaccines. We know this from looking at the results of clinical trials, and from the reports from the millions of people around the world who have already been vaccinated. We know that serious side effects to vaccines, like an allergic reaction, are extremely rare. As more people in Ireland and around the world get this vaccine, the HSE will update our website with any new information. You can report any side effects you experience to the HPRA. The link is below. #GETTING THE VACCINE AND YOUR APPOINTMENT #COVID-19 HEALTH SCREEN: Do not attend your appointment if • you have any current symptoms of Covid 19 or • have been diagnosed with Covid 19 in the last 4 weeks or • have been told you are a close contact of someone with Covid 19 or • have been told you should isolate or • have recently returned from foreign travel #WHEN YOU SHOULD NOT GET A COVID VACCINE: • Following an anaphylactic reaction to a first dose of a Covid Vaccine • If you are allergic to any of the ingredients contained in the vaccine as listed further below #APPOINTMENT TIMES: • You should allow at least 30 minutes for your vaccination appointment. After getting the vaccine, you will be under observation for 15 minutes. • Please be on time but do not arrive to the pharmacy more than 5 minutes before your appointment • You will be sent a reminder prior to your appointment • If you need to cancel or reschedule your appointment please contact the pharmacy as soon as you can • Adults should arrive for their vaccination unaccompanied where possible #ON THE DAY: • Please where a loose fitting top so that your upper arm is easily accessible • Bring your phone, photo ID and a face covering • If this is your second vaccination dose please bring your vaccination record card #VACCINE INFORMATION LEAFLETS: Please read the relevant information about your assigned vaccine prior to your appointment. Leaflets will also be available at the pharmacy when you arrive for your vaccination. [• Johnson & Johnson Vaccine leaflet](https://www.hse.ie/eng/services/news/newsfeatures/covid19-updates/covid-19-vaccine-materials/important-information-about-the-covid-19-vaccine-janssen.pdf) [• PfizerBioNTech Vaccine leaflet](https://www.hse.ie/eng/services/news/newsfeatures/covid19-updates/covid-19-vaccine-materials/covid-19-vaccine-information-leaflet-after-18-jan.pdf) #VACCINE EXCIPIENT LIST: Johnson & Johnson Vaccine: 2- hydroxypropyl-β-cyclodextrin (HBCD),Citric acid monohydrate, Ethanol, Hydrochloric acid,Polysorbate-80, Sodium chloride, Sodium hydroxide Trisodium citrate dihydrate, Water for injections PfizerBioNTech Vaccine: polyethylene glycol/macrogol (PEG) as part of ALC-0159, ALC-0315 = (4-hydroxybutyl) azanediyl)bis (hexane-6,1-diyl)bis(2-hexyldecanoate),, ALC-0159 = 2-[(polyethylene glycol)-2000]-N,N-ditetradecylacetamide,, 1,2-Distearoyl-sn-glycero-3-phosphocholine, cholesterol, potassium chloride, potassium dihydrogen phosphate, sodium chloride, disodium hydrogen phosphate dihydrate, sucrose, water for injections. #FURTHER INFORMATION: For more up-to-date Covid related information please follow the links below or contact the HSE on 1850 24 1850. [Health Products Regulatory Authority](https://www.hpra.ie/) [HSE Immunisation website](https://www.hse.ie/eng/health/immunisation/hcpinfo/covid19vaccineinfo4hps)

Consent Text
Default Text
I have read and understand the vaccine information provided, including known side effects.

I understand that the Johnson & Johnson COVID-19 vaccine is not recommended during pregnancy.

I understand that the Pfizer BioNTech COVID-19 vaccine is only recommended to be given between week 14 and week 36 of pregnancy.

I understand that I am giving consent for the administration of a COVID-19 vaccine including a 2nd dose, if required.
Would you like to modify the default consent text for "Covid-19 Vaccination"?

YesNo
Please enter your custom Consent Text for "Covid-19 Vaccination" below
Custom Consent Text for "Covid-19 Vaccination"
I have read and understand the vaccine information provided, including known side effects. I understand that the Johnson & Johnson COVID-19 vaccine is not recommended during pregnancy. I understand that the Pfizer BioNTech COVID-19 vaccine is only recommended to be given between week 14 and week 36 of pregnancy. I understand that I am giving consent for the administration of a COVID-19 vaccine including a 2nd dose, if required.

Patient Questionnaire
Default Text
Date of birth dd/mm/yyyy:
Address:
GP Name:
Mother's birth surname (used by HSE to identify you):
Gender (used by HSE to identify you):
Ethnicity (used by HSE to identify you):
Have you had anaphylaxis (serious systemic allergic reaction requiring medical intervention) following a previous dose of any vaccine or any of the constituents of the COVID-19 vaccines, including polyethylene glycol or polysorbate 80?
Have you been diagnosed with COVID-19 within the last 4 weeks?
Have you had another vaccine within the last 14 days?
Do you have a bleeding disorder or are you on anticoagulation therapy?
Are you pregnant?
Would you like to modify the default Patient Questionnaire?

YesNo
Please enter your custom Patient Questionnaire Text below
Patient Questionnaire
Date of birth dd/mm/yyyy: Address: GP Name: Mother's birth surname (used by HSE to identify you): Gender (used by HSE to identify you): Ethnicity (used by HSE to identify you): Have you had anaphylaxis (serious systemic allergic reaction requiring medical intervention) following a previous dose of any vaccine or any of the constituents of the COVID-19 vaccines, including polyethylene glycol or polysorbate 80? Have you been diagnosed with COVID-19 within the last 4 weeks? Have you had another vaccine within the last 14 days? Do you have a bleeding disorder or are you on anticoagulation therapy? Are you pregnant?

Next Steps
Please press submit below to send on the information supplied. We will contact you in the coming days with instructions to integrate the booking form on to your website.
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COVID-19 Vaccine Booking Form Setup

Staff Member Login

Appointment Settings

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