Covid-19 Vaccine Questionnaire

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Personal Details

Gender: *

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Covid-19 Questionnaire

Please answer each question below to check you meet the specified criteria for the Covid-19 Vaccination.

Are you able to safely travel to the practice?: *

Sorry, we cannot continue. Please call the surgery as we may need additional information from you.

Do you agree to wear a face masks at all times when on the vaccination premises, and to ensure the face mask fits correctly and covers your nose?: *

Sorry, we cannot continue. Please call the surgery as we may need additional information from you.

Have you ever had an anaphylactic reaction to a drug/vaccine (i.e. required an EpiPen or hospital admission) or an unexplained anaphylactic reaction?: *

Sorry, we cannot continue. Please call the surgery as we may need additional information from you.

Are you planning or have you had another vaccination in the 7 days prior to or 7 days after the planned date of the Covid vaccination?: *

Sorry, we cannot continue. Please call the surgery as we may need additional information from you.

(Female Questions) Are you under 55 years of age?: *

(Female Questions) Are you pregnant?: *

Sorry, we cannot continue. Please call the surgery as we may need additional information from you.

You will be sent more information prior to your appointment and will be formally consented on the day, however do you think you are likely to consent for and proceed with covid vaccination?: *

Sorry, we cannot continue. Please call the surgery as we may need additional information from you.

Ideal time of day for an appointment?: *

Please submit your answers to the practice.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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