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Covid-19 Client Detail –
Appointment Booking Form

Fill in your details

Make an appointment

We will confirm your appointment

    Section 1: Please complete as many fields as possible below.

    Date of birth

    (You will need to bring age identification with you to pharmacy at the time of your appointment.)

    Phone Number

    Email

    Indicate which vaccination cohort (if unsure please ask a member of the pharmacy team)


    Ethnicity:


    Section 2: Personal Details:

    Section 3: GP Details

    • You do not have any current symptoms of Covid 19
    • You have been diagnosed with Covid 19 in the last 4 weeks.
    • You have not been told you are a close contact of someone with Covid 19
    • You have not been told you should isolate
    • You have not recently returned from foreign travel

    Please select your local pharmacy

    Preferred Vaccine:

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