COVID-19 Vaccination

Registration of Interest

If you have yet to receive your COVID-19 Vaccination and wish to avail of a pharmacy appointment, complete this form to be notified of vaccine availability from your nearest participating totalhealth Pharmacy. The pharmacy team will contact you if they can offer you an appointment.

Please note: Completion of this form does not guarantee vaccine availability or eligibility. Participating pharmacies, and which vaccines they can administer, are determined by the HSE. The recommended age-groups for each vaccine is subject to change by the HSE; please monitor the HSE website, news and social media for updates.

Registration for people under the age of 16 years must include the name of a parent or legal guardian who will accompany them to a vaccine appointment to provide the necessary consent.

After you register, please remember to contact the pharmacy if you secure an appointment elsewhere so they can remove you from their waiting list.

Privacy Notice: By completing this form, you agree that your information will be sent to your chosen totalhealth Pharmacy, who will use the details you provided to contact you and organise an appointment if available. Your information is not stored on this website.

Complete this form with the details of the person requesting vaccination

Choose your Pharmacy *

First Name *

Surname *

Date of Birth (DD/MM/YYYY) *

Mobile Number *

Email Address *

PPSN *

Eircode *

GP Name *

Is the person requesting vaccination a healthcare worker? *

Yes

Is the person requesting vaccination pregnant? *

Yes

Are you in an at risk group, if so please state which group? *

Date of Last Vaccination (if applicable)

If the person requesting vaccination is under 16 years of age, please include the name of the parent or guardian that will accompany them to their appointment

Parent/Guardian Name

* Denotes required field

Send

COVID-19 Vaccination

Registration of Interest

After you register, please remember to contact the pharmacy if you secure an appointment elsewhere so they can remove you from their waiting list.

More Information on the totalhealth COVID-19 Vaccination Service can be found here

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