COVID-19 Vaccination

Last Updated: 23/03/2021

Your Details

Please complete the following information if you have already booked your COVID-19 Vaccination

Name *

Did you book your first vaccination at a centre that is not Buckhurst Way Clinic? *

Yes No

Did you book your second vaccination at a centre that is not Buckhurst way clinic? *

Yes No

Date of Birth *

Consent

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

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COVID-19 Vaccination

Further Information