Covid Booster Booking Form

The following form will take approximately 5-10 minutes to fill out and you will need to have you PPS number and Eircode.

Name(Required)

First Middle Last

If you are booking a booster for a child aged 12 years or older, all the information given should apply to the child your are booking for

Gender(Required)

Male

Female

Are you pregnant?(Required)

Yes

Email(Required)

Enter Email Confirm Email

Phone

Mother's Birth Surname

Date of Birth(Required)

DD slash MM slash YYYY

Address(Required)

Street or town Town (if none add none to box) County Eircode

Are you completing this form for a child aged under 16 years of age?(Required)

Yes

Please note children under 16 years of age must be accompanied by an adult guardian/parent who must give consent for them to receive their vaccination. Children aged 16 and 17 years of age can give their own consent and can come alone

Please provide the Parent / Legal Guardian name(Required)

Please enter the PPSN of the person to be vaccinated(Required)

A PPS Number is always 7 numbers followed by either one or two letters. If you do not have one enter xxxxxxxxx (9 x's)

Have you ever had a serious allergic reaction (anaphylaxis) that needed medical treatment: after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine, OR to any of the vaccine ingredients, including polyethylene glycol known as PEG OR to any other previous vaccine (including the flu vaccine)?(Required)

Yes

Do you have an allergy to any of the following ingredients contained in the Pfizer Comirnaty vaccine?(Required)

Yes

(4-hydroxybutyl)azanediyl)bis(hexane-6,1-diyl)bis(2-hexyldecanoate) (ALC-0315), 2-[(polyethylene glycol)-2000]-N,N-ditetradecylacetamide (ALC-0159), 1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC), cholesterol, trometamol, trometamol hydrochloride, sucrose, water for injections

Have you ever had a serious allergic reaction (anaphylaxis): after taking multiple different medications, with no reason known for the reaction. This may mean you are allergic to polyethylene glycol (PEG) OR after having a vaccine or a medicine that contains polyethylene glycol (PEG), OR unexplained reasons? This may mean you are allergic to polyethylene glycol (PEG)(Required)

Yes

Do you have an allergy to Trometamol (a contrast dye use in MRI radiological studies) and contained in Pfizer vaccines?(Required)

Yes

Have you had pericarditis (inflammation of the lining around the heart) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine?(Required)

Yes

Have you had myocarditis (inflammation of the heart muscle) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID19 vaccine?(Required)

Yes

Have you ever had: Mastocytosis (rare condition caused by an excess number of mast cells gathering in the body's tissues) OR idiopathic anaphylaxis. This is a condition diagnosed by an immunologist. OR a serious allergic reaction (anaphylaxis) due to food, medication or venom from an insect or animal?(Required)

Yes

Do you have a history of capillary leak syndrome?(Required)

Yes

Are you at risk of lymphoedema in both arms?(Required)

Yes

If you are at risk of lymphoedema in BOTH arms the vaccination service in the pharmacy will not be suitable for you, contact our pharmacist for further advice.

Do you suffer from any bleeding disorder or are you taking anticoagulant medication such as warfarin/Eliquis/ Pradaxa/Lixiana or Xarelto?(Required)

Yes

Which COVID-19 vaccine dose do you wish to book an apppointment for?(Required)

Booster 1

Booster 2

Booster 3

To determine which booster you are eligible for please consult HSE guidelines by clicking on the link below (please note that the "primary course" of vaccination is two Pfizer, Moderna or Astra Zeneca vaccines or one Janssen vaccine each vaccine after these are called boosters)

HSE Booster Vaccines Information

Are you booking a booster due to being in a very high risk or high risk group (as your age group is currently not eligible for vaccination)? Please note we will ask you when you present for your vaccine what your reason for vaccination is and may refuse to vaccinate you if you are outside the current age HSE age group and do not have a valid risk condition(Required)

Yes

For Booster 3 please click on the Booster 3 eligibility outside being over 65 or older list For Booster 2 please click on the Booster 2 eligibility outside being over 50 or older list

Booster 3 eligibility outside being over 65 or older list

Booster 2 eligibility outside being over 50 or older list

Do you have a regular G.P?(Required)

Yes

Please give the name of you G.P. and the practice address(Required)

What is your ethnicity?(Required)

Prefer not say

Irish

Irish Traveller

Any other white background

African

Any other black background

Chinese

Any other Asian background

Roma

Other (incl. mixed background)

What is your nationality?(Required)

Comments

This field is for validation purposes and should be left unchanged.