• COVID Vaccination Booking Form

    Please fill in details below and click 'Submit.' Your residential nurse or health & wellbeing staff member will coordinate the date and time of your appointment with you.
  • Format: 0000-000-000.
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  • Medical Conditions (Tick only those that apply)
  • Have you ever had a severe reaction following any vaccine or medication (such as anaphylaxis)?*
  • Do you have any severe allergies to anything?*
  • Have you had COVID-19 before?*
  • Have you ever received a COVID-19 vaccine?*
  • Have you received any other vaccination in the last 7 days?*
  • Do you have a bleeding disorder or take any blood thinning medications (e.g. warfarin, heparin, anticoagulant therapy)?*
  • Have you ever fainted or felt dizzy after having an injection?*
  • Do you have a weakened immune system (immunocompromised)?*
  • Have you had a serious adverse event, that following expert review was attributed to a previous dose of a COVID-19 vaccine?*
  • Have you ever had mastocytosis (a mast cell disorder) which has caused recurrent anaphylaxis?*
  • Have you ever been diagnosed with capillary leak syndrome?*
  • Have you been diagnosed with myocarditis and/or pericarditis after a previous dose of COVID-19 vaccine?*
  • Have you had myocarditis or pericarditis in the last 3 months?*
  • Do you currently have acute rheumatic fever or acute rheumatic heart disease?*
  • Do you have severe heart failure?*
  • Should be Empty: