COVID vaccine
registration
First name
Last name
Phone
PPS number
Date of birth
Address
Which group are you in?
Group 1
People aged 65 and older who live in long-term care facilities
Group 2
Frontline healthcare workers
Group 3
People aged 70 and older
Group 4
People aged 16 to 69 who are at very high risk from conditions such as:
Cancer (All cancer patients actively receiving (and/or within 6 weeks of receiving) systemic therapy with cytotoxic chemotherapy, targeted therapy, monoclonal antibodies or immunotherapies and radical surgery or radiotherapy for lung or head and neck cancer.
All patients with advanced/metastatic cancers.)
Chronic kidney disease
Chronic neurological disease or condition
Chronic respiratory disease
Diabetes (Diabetes and HbA1C ≥58mmol/mol)
Immunocompromised
Inherited metabolic diseases
Intellectual disability
Obesity (BMI >40 Kg/m2)
Sickle cell disease
People at very high risk attending hospital or disability services
People at very high risk not attending regular hospital services
Group 5
People aged 65 to 69 at high risk from conditions such as:
Cancer (Haematological - within 1 year. Haematological - within 1 - 5 years. Non-haematological - within 1 year. All other cancers on non-hormonal treatment.)
Chronic heart (and vascular) disease
Chronic kidney disease
Chronic liver disease
Chronic neurological disease or condition
Chronic respiratory disease Diabetes (All other diabetes (Type 1 and 2))
Immunocompromised
Inherited metabolic diseases
Intellectual disability
Obesity (BMI >35 Kg/m2)
Severe mental illness
Group 6
Other people aged 65 to 69
Group 7
People aged 16 to 64 at high risk from conditions such as:
Cancer (Haematological - within 1 year. Haematological - within 1 - 5 years. Non-haematological - within 1 year. All other cancers on non-hormonal treatment.)
Chronic heart (and vascular) disease
Chronic kidney disease
Chronic liver disease
Chronic neurological disease or condition
Chronic respiratory disease Diabetes (All other diabetes (Type 1 and 2))
Immunocompromised
Inherited metabolic diseases
Intellectual disability
Obesity (BMI >35 Kg/m2)
Severe mental illness
Group 8
Other people aged 60 to 64
Group 9
Other people aged 16 to 59
Group 10
None of the above
Did you already receive first dose of any Covid Vaccines?
Yes
Yes I did receive one before
No
No I did not. This is my first vaccine
Give details of where, when and what type of vaccine did you receive
Do you consent to receive covid vaccination?
Yes
I hereby consent to receive Covid-19 vaccine.
No
I do not consent to receive Covid-19 vaccine.
Book your place in the queue