Covid Vaccine Form 2

1

Are you a patient of the practice above 16 years of age?If no please contact the surgery

YESNO

2

Name

First Name

Last Name

3

Phone Number

Please enter a valid phone number.

4

Date of Birth

Date

5

Do you have a history of anaphylactic reactions?

YESNO

6

Have you been diagnosed with Covid19 infection within the last 4 weeks?

YESNO

7

Have yo had any other vaccination in the last 4 weeks?

YESNO

8

Do you have a history of bleeding disorders?

YESNO

9

Are you currently pregnant?If yes please contact the surgery

YESNO

10

Please read the Pfizer vaccine information bellow including side effectshttps://www.hse.ie/eng/services/news/newsfeatures/covid19-updates/covid-19-vaccine-materials/covid-19-vaccine-information-leaflet-after-18-jan.pdf

I have read and agree

I do NOT agree

11

Please wear short sleeve's so we can access your upper arm easily

I acknowledge

12

We will contact you shortly with confirmation of appointment date and time. If you have not heard back in 3 working days please contact the surgery on 090 9675107

Will do