Covid-19 Client Detail – Appointment Booking FormFill in your detailsMake an appointmentWe will confirm your appointmentFill in your detailsMake an appointmentWe will confirm your appointment Section 1: Please complete as many fields as possible below. Gender (indicate)MaleFemale 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) Residents and sta of long term care facilitiesFront line Health Care WorkersPeople with a VERY HIGH risk medical conditionPeople with a HIGH risk underlying conditionKey workers essential to the vaccination programmePeople living or working in crowded settingsAllocation group based on age Ethnicity: IrishIrish TravellerAny other white backgroundAny other black backgroundAfrican ChineseAny other Asian backgroundRomaOther (including mixed background)Prefer not to say No PPS Number Section 2: Personal Details: Section 3: GP Details Not Registered with a GP Please confirm the following on the day of your appointment and bring this form with you. 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 Select Local PharmacyLavelle’s Life Pharmacy BelmulletLavelles Pharmacy Galway I fully understand the questions asked & have answered honestly and truthfully. I fully understand the side-effects of the treatment options, their effectiveness and alternative options & am happy to continue with my request. Preferred Vaccine: Pfizer (Two dose vaccine) I confirm & agree that any treatment prescribed for me is for my personal use only.
