Here is a friendly reminder email of your appointment

Appointment

{appointment35:date}

Duration

{appointment35:duration}

Timezone

{appointment35:timezone}

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{form_title}

Surname / Family Name	{q3_textbox1}
Forename	{q4_textbox2}
Gender	{q5_radio3}
Date of Birth	{q6_datetime4}
PPSN	{q7_textbox5}
Email Address	{q8_email6}
Mobile Phone Number	{q9_phone7}
Address	{address}
Are you 50 years of age or older?	{q16_radio14}
Are you 18 years of age or older and at increased risk of Herpes Zoster (Shingles)?	{q17_radio15}
Do you have thrombocytopenia or any coagulation disorder?	{q18_radio16}
Do you feel unwell in any way?	{q19_radio17}
Are you pregnant or breastfeeding?	{q20_radio18}
Are you at risk of lymphoedema in any limb?	{q21_radio19}
Do you have a condition or are you receiving treatment (such as a combination checkpoint inhibitor) that could affect your immune system?	{q22_radio20}
Have you ever had an allergic reaction to any previous vaccination?	{q23_radio21}
Are you allergic to any of the vaccine residues or excipients?	{q24_radio22}
Have you ever suffered an anaphylactic reaction?	{q25_radio23}
Have you had a Herpes Zoster (Shingles) infection in the last 12 months?	{q26_radio24}
Please list any current medical conditions, medications, or allergies	{q27_textarea25}
Appointment	{appointment}
Appointment	{appointment35}

McGreals Portalington