COVID-19 Vaccine Registration Form

Q1.) Do you consent to receive Moderna COVID19 vaccine?

Yes

Note: We are not in a position to administer the vaccine. Thank you!

Q2.) Do you consent us to process or retain your personal information according to GDPR regulations?

Yes

Note: We are not in a position to administer the vaccine. Thank you!

Q3.) Have you had COVID19 vaccine or COVID 19 positive test in the last 4 months? If yes then you are not eligible for the booster dose until at least 4 months have passed.

Yes

Note: We are not in a position to administer the vaccine. Thank you!

Q4.) Moderna vaccine is only available for people age 30 year or older ?

Please enter your date of birth

If age less than 30 years then you are not eligible for the Moderna vaccine. Please contact Getting your COVID-19 vaccine - HSE.ie for alternative options.

Name

Surname

PPS Number

Mobile Number

Current Category

Previous vaccine type

Q5.) Did you ever had anaphylaxis or systemic allergic reaction to any vaccine or to any of the vaccine constituents or any injectable therapy?

Yes

Note: We are not in a position to administer the vaccine. Thank you!

Please contact HSE Getting your COVID-19 vaccine - HSE.ie for safer and observed location options. We are not in a position to administer the vaccine. Thank you