Online vaccine booking - Blessington Pharmacy

Patient Name*

First NameLast Name

Age*

Phone Number

Please enter a valid phone number.

E-mail*

Confirmation Emailexample@example.com

Address

Street Address

Street Address Line 2

CityCounty

Sex at Birth*

FemaleMale

Date of Birth*

Date

Mother’s Surname at Birth:

PPS Number*

Please select vaccines you would like to receive:*

Covid-19 booster (Pfizer)Flu vaccine

Prevaccination Checklist

When booking your vaccine appointment, answering the questions on the form is not required to secure your slot. However, providing this information in advance will help us register your details more quickly and make your visit to the pharmacy smoother. Thank you!

When did you receive your last dose of Covid-19 vaccine?

Have you ever had an allergic reaction to:

(This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing)

A component of the COVID-19 vaccine, including polyethylene glycol (PEG), which is found in some medications, such as laxatives and preparations for colonoscopy procedures:

YesNo

Polysorbate:

YesNo

A previous dose of COVID-19 vaccine:

YesNo

Have you ever had an allergic reaction to another vaccine or an injectable medication?

YesNo

This would include a severe allergic reaction [e.g., anaphylaxis] that required treatment with epinephrine or EpiPen® or that caused you to go to the hospital. It would also include an allergic reaction that occurred within 4 hours that caused hives, swelling, or respiratory distress, including wheezing.)

Have you ever had a severe allergic reaction (e.g., anaphylaxis)? This would include food, pet, environmental, oral medication allergies, vaccines, injectable medication?

Yes

Have you received any vaccine in the last 14 days?

YesNo

Have you ever had a positive test for COVID-19 or has a doctor ever told you that you had COVID-19?

YesNo

When you had COVID-19 infection?

Do you have a weakened immune system or do you take immunosuppressive drugs or therapies?

YesNo

Do you live with someone who is severely immunocompromised?

YesNo

Do you have a bleeding disorder or are you taking a blood thinner?

YesNo

Have you every had a breast surgery?

YesNo

Are you pregnant or breastfeeding?

YesNo

Appointment*