Vaccination Appointment Request
Serving Lichfield, Tamworth & surrounding areas. Walk-ins are welcome, or use this form to request a vaccination appointment. Same day appointments are available.
Which vaccine are you booking today?
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NHS Flu Vaccine
Flu & Covid Vaccines (same appointment)
COVID-19 Vaccine
Private Flu Vaccine
Travel Vaccines
Hajj/Umrah Vaccines
Not sure - please advise me
Where are you traveling to?
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Do you know what dates you are traveling?
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Day
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Month
Year
Date
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Do you have any allergies we should be aware of?
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Yes I do - please provide details below
No I don't
Unsure
Please provide details of any allergies
Do you have any medical conditions we should be aware of?
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Yes I do - please provide details below
No I don't
Unsure
Please provide details of medical conditions
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Choose your Appointment Date & Time
Let us know what works best for you. We'll confirm your booking shortly.
Preferred Appointment Date & Time
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Preferred Appointment Date & Time
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Your Details
Please provide your contact information so we can confirm your booking
Full Name
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First Name
Last Name
Date of Birth
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Day
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Month
Year
Date
Phone Number
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Country Code
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Area Code
Phone Number
Email Address
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Confirmation Email
example@example.com
NHS Number (if known)
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Tick the box to confirm you're happy to proceed.
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I can confirm the information I have provided is accurate to the best of my knowledge, and I understand this is a request for a vaccination appointment. The pharmacy will contact me to confirm my booking.
Submit
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