Home Vaccination Consent (Housebound Patient)

Patient Details

Full Name *

Address Line 1 *

Town *

Postcode *

Date of Birth *

Telephone Number *

Do you consent to receiving the COVID-19 vaccination?

Yes

No

Communicate with Next of Kin is preferable for me

Yes

No

GP Surgey

Next of Kin Details (if applicable)

Full Name *

Telephone Number *

NOK Email Address

Optional

Relationship to Service User *

e.g. Husband, Daughter, Carer, Neighbour

Access to home information

Are there any access issues we should be aware of? (e.g. stairs, parking restrictions, entry systems, pets, mobility concerns)

Yes (please specify)

No

*

e.g. Keysafe Number, Patient will answer door, Go round to back door

GDPR Consent

*

I consent to my data being held by Christchurch Health Centre (Clinics, Pharmacy, & Cares)

*

I consent to my data being supplied to my GP surgery following vaccination

I consent to being contacted by Christchurch Health Centre regarding my enquiry, appointments, and relevant health services. I understand I can withdraw my consent at any time.

If no, please provide reason (optional):

Additional Information:

Please include any other relevant details (e.g. preferred times, medical considerations, communication needs)

Signed

*

Clear

Ear, Nose, & Throat

Infections & Minor Illness

Lifestyle

Skin

Vaccinations

Women's Health

Men’s Health

Aesthetics

Blood Pressure Check

Chickenpox

COVID-19 Vaccination

Cryotherapy

Earwax Removal

Family Planning

Flu Vaccination

Hair Loss

Hepatitis B

HPV

Menopause

Mole Check

Pneumococcal Vaccine

Private GP Services

Shingles Vaccination

Travel Vaccination Clinic

Vitamin B12 Treatment

Weight Management

Yellow Fever Vaccination

Book Appointment

Contact

Pricelist

NHS Services

Contraceptive Pill Repeat Supply

Ear Infection

(1-17 Years)

Impetigo Sores

(1+)

Infected Bug Bites

(1+)

NHS Cardiovascular Heath Check

NHS Stop Smoking Support

Shingles Rash

(18+)

Sinusitis

(12+)

Sore Throat

(5+)

Urine Infection

(Women 16-64 Yrs)

Private Services

Cardiovascular Heath Check

Erectile Dysfunction Treatment

Period Delay

Weight Loss Pre-Assessment

Book Appointment

Contact

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