Covid Vaccine Form 2 Notify Patient InformationHealth History Book an appointmentCovid-19 VaccineConsent Welcome to our Covid Vaccine FormFirst NameLast NameEmailPhone/MobileAddress Line 1CityPostcodeCountryUnited KingdomUnited Kingdom (UK)Date of birth Sex at birth Male FemalePreviousNext Do you have any allergies to medications, foods, or vaccines (e.g., eggs, latex)? Yes NoPlease expand on the allergy and type of reaction Have you ever had a serious reaction to a vaccine in the past? Yes NoPlease explain your symptomsDo you have any chronic health conditions (e.g., asthma, diabetes, heart disease)? Yes NoPlease expand on your health conditionsAre you currently pregnant? Yes NoAre you currently breastfeeding? Yes NoDo you have a weakened immune system (e.g., HIV/AIDS, cancer, medications that affect the immune system)? Yes NoPlease detail your conditions Have you received any other vaccines in the past 4 weeks? Yes NoPlease detail the vaccines and when you took them Have you ever received the Influenza vaccine before? Yes NoPlease detail when you had itDo you have a bleeding disorder or are you taking blood-thinning medications? Yes NoPreviousNextWhich of the following exemption categories apply to you? No Exemption - Private Aged 75 or over Live in a care home Currently pregnant ImmunosuppressedImmunosupressed individuals include: - Patients undergoing Chemotherapy - Patients undergoing radical radiotherapy- Solid organ transplant recipients- Patients on immunosuppressive medications Select Appointment Date & TimeSelect Appointment Date & Time£90 - Private Covid Vaccine  PreviousNext£90.00 - Private Covid VaccinePreviousNextVaccine Information and Consent Covid vaccine - Please read the following information carefully: Common side effects: Pain at the injection site, headache, fever, muscle aches, and mild fatigue. Serious side effects: Severe allergic reactions are rare but can occur. The Covid vaccine is recommended to protect against the respiratory virus.Covid vaccine - Please read the following information carefully: Common side effects: Pain at the injection site, headache, fatigue, fever, muscle pain, chills, and nausea. Serious side effects: Severe allergic reactions are rare but can occur. The COVID-19 vaccine is recommended to protect against the coronavirus disease (COVID-19), a contagious respiratory illness caused by the SARS-CoV-2 virus. The vaccine is usually given as an injection in a series of doses, depending on the specific vaccine I have read the information about the Influenza vaccine. I understand the benefits and risks of the Influenza vaccine and request that the vaccine be given to me or to the person named above for whom I am authorised to make this request. I have read the information about the COVID-19 vaccine. I understand the benefits and risks of the COVID-19 vaccine and request that the vaccine be given to me or to the person named above for whom I am authorised to make this request.£0.00 for each month Previous Submit Form
