COVID-19 Vaccine Appointment Form

Which location are you booking for?*

Hairini Marae (02 Feb) 9 Tamahika St, Tauranga*

Maketu Hauora (11 Feb) 3 Little Waihi Road*

Maketu Hauora (25 Feb) 3 Little Waihi Road*

Tamapahore Marae (16 Feb) 46 Tareha Lane, Mangatawa*

Te Tomika Trust (09 Feb) 60 Grace Road, Tauranga*

Hairini Marae (23 Feb) 9 Tamahika St, Tauranga*

Rangiuru Sports Club (03 Feb) Cnr of Jellicoe Street and No 3 Road, Te Puke*

Rangiuru Sports Club (10 Feb) Cnr of Jellicoe Street and No 3 Road, Te Puke*

Rangiuru Sports Club (17 Feb) Cnr of Jellicoe Street and No 3 Road, Te Puke*

Rangiuru Sports Club (14 Feb) Cnr of Jellicoe Street and No 3 Road, Te Puke*

Rangiuru Sports Club (21 Feb) Cnr of Jellicoe Street and No 3 Road, Te Puke*

Poutiri Wellness Centre (28 Feb) (Jellicoe Street entrance side), Te Puke*

Matakana Island (08 Feb) Te Awanui Hauora*

Matakana Island (22 Feb) Te Awanui Hauora*

Tamapahore Marae (21 Jan) 46 Tareha Lane, Mangatawa*

Matakana Island (25 Jan), Te Awanui Hauora*

Maketu Hauora (28 Jan), 3 Little Waihi Road*

Poutiri Wellness Centre (24 Jan), 35 Commerce Lane, Te Puke*

Poutiri Wellness Centre (26 Jan), 35 Commerce Lane, Te Puke*

Poutiri Wellness Centre (20 Jan), 35 Commerce Lane, Te Puke*

Poutiri Wellness Centre (19 Jan), 35 Commerce Lane, Te Puke

Poutiri Wellness Centre (17 Jan), 35 Commerce Lane, Te Puke*

Poutiri Wellness Centre (11 Jan), 35 Commerce Lane, Te Puke*

Poutiri Wellness Centre (12 Jan), 35 Commerce Lane, Te Puke*

Poutiri Wellness Centre (13 Jan), 35 Commerce Lane, Te Puke*

Poutiri Wellness Centre (14 Jan), 35 Commerce Lane, Te Puke*

Poutiri Wellness Centre (01/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (03/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (08/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (10/11), 35 Commerce Lane, Te Puke *

Maketu Hauora (12/11) - 3 Little Waihi Road, Maketu

Poutiri Wellness Centre (13/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (15/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (17/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (20/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (22/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (24/11), 35 Commerce Lane, Te Puke

Maketu Hauora (26/11) 3 Little Waihi Road, Maketu*

Poutiri Wellness Centre (27/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (29/11), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (04/12), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (18/12), 35 Commerce Lane, Te Puke *

Poutiri Wellness Centre (PM4/10), 35 Commerce Lane, Te Puke 04/10 *

Poutiri Wellness Centre (PM 11/10), 35 Commerce Lane, Te Puke 11/10 *

Poutiri Wellness Centre (PM 18/10), 35 Commerce Lane, Te Puke 18/10 *

Poutiri Wellness Centre (AM4/10), 35 Commerce Lane, Te Puke 04/10 *

Poutiri Wellness Centre AM 11/10), 35 Commerce Lane, Te Puke 11/10 *

Poutiri Wellness Centre (AM 18/10), 35 Commerce Lane, Te Puke 18/10 *

Poutiri Wellness Centre, 35 Commerce Lane, Te Puke 02/10 *

Poutiri Wellness Centre, 35 Commerce Lane, Te Puke 06/10 *

Poutiri Wellness Centre, 35 Commerce Lane, Te Puke 09/10 *

Poutiri Wellness Centre (13/10), 35 Commerce Lane, Te Puke 13/10 *

Rangiuru Sports Club, Te Puke 14/10 *

Poutiri Wellness Centre, 35 Commerce Lane, Te Puke 16/10 *

Poutiri Wellness Centre, 35 Commerce Lane, Te Puke 20/10 *

Poutiri Wellness Centre, 35 Commerce Lane, Te Puke 23/10 *

Poutiri Wellness Centre, 35 Commerce Lane, Te Puke 27/10 *

Poutiri Wellness Centre, 35 Commerce Lane, Te Puke 30/10 *

Te Puke Baptist Church, Station Rd Te Puke*

Affco carpark, Te Puke Highway*

Maketu Hauora - 3 Little Waihi Road, Maketu 01/10*

Maketu Hauora - 3 Little Waihi Road, Maketu 15/10*

Maketu Hauora - 3 Little Waihi Road, Maketu 29/10*

Hairini Marae (13/10) - 9 Tamahika Street, Hairini 13/10*

Hairini Marae - 9 Tamahika Street, Hairini 27/10*

Who are you booking for?

YourselfYourself and others in the same whānau bubble (coming in the same car)

How many are you booking for?

Your Name*

First NameLast Name

Your Date of Birth*

Date

Bookings can only be made for those who are 5 years of age and over

Your Email*

If you don’t have an email - please type pahi@poutiri.org

Your Address*

Your Phone Number*

Area CodePhone Number

Is this your 1st dose, 2nd dose or Booster of COVID-19 vaccine? *

First DoseSecond DoseBooster ( available for those 18 years + only / 3 months since 2nd dose)

If second dose - when did you have your first dose? *

Date

Whānau member #1*

First NameLast Name

Date of Birth*

Date

Bookings can only be made for those who are 5 years of age and over

Phone Number*

Area CodePhone Number

What is your ethnicity?*

Is this your 1st dose, 2nd dose or Booster of COVID-19 vaccine?*

First DoseSecond DoseBooster ( available for those 18 years + only / 3 months since 2nd dose)

Add Whanau member #2?

YesNo

Whānau member #2*

First NameLast Name

Date of Birth*

Date

Bookings can only be made for those who are 5 years of age and over

Phone Number*

Area CodePhone Number

What is your ethnicity?*

Is this your 1st dose, 2nd dose or Booster of COVID-19 vaccine?*

FirstSecondBooster ( available for those 18 years + only / 3 months since 2nd dose)

Add Whanau member #3?

YesNo

Whānau member #3*

First NameLast Name

Date of Birth*

Date

Bookings can only be made for those who are 5 years of age and over

Phone Number*

Area CodePhone Number

What is your ethnicity?*

Is this your 1st dose, 2nd dose or Booster of COVID-19 vaccine*

FirstSecondBooster ( available for those 18 years + only / 3 months since 2nd dose)

Add Whanau member #4?

YesNo

Whānau member #4*

First NameLast Name

Date of Birth*

Date

Bookings can only be made for those who are 5 years of age and over

Phone Number*

Area CodePhone Number

What is your ethnicity?*

Is this your 1st dose, 2nd dose or Booster of COVID-19 vaccine*

FirstSecondBooster ( available for those 18 years + only / 3 months since 2nd dose)

If you selected Māori, please tell us your iwi/hapū affiliations (optional)

If you selected Other,please let us know your iwi affiliations for our own internal reporting purposes (optional)

National Health Index (NHI) Number - you can find your NHI on: a prescription receipt, medicine bottle label, hospital letter, x-ray or test result (optional)

If this is for your 2nd dose - when did you have your first dose? The minimum gap between your first and second vaccine should be 6 weeks

Date

How would you rate your well-being (mental, emotional, physical, spiritual) during this lockdown period?

Has your whānau income been affected due to lockdown?

YesNo

Do need help to access kai/food?

YesNo

Are you struggling to access any regular medications you may be on?

YesNo

Is there anything else you would like help with?

YesNo

If YES - please provide details below:

COVID19 Vaccination Booking & Hauora Check

Questions marked with * are required

Provide additional information