COVID Vaccination Appointment Request

Please only complete this form when you have been contacted individually by the practice.

We are rapidly booking in large numbers of patients for vaccinations. The appointments are being offered on a priority basis as defined by the Joint Committee of Vaccination and Immunisation (JCVI). We must follow this priority list.

Based on national guidance we must provide the first dose of the vaccine to as many people as possible. If you have already had the first dose of vaccine, please do not complete this form.

COVID Vaccination Appointment Request

COVID Vaccination Appointment Request

The priority groups as defined by the JCVI are:

1 - Residents in a care home for older adults and their carers
2 - All those 80 years of age and over and frontline health and social care workers
3 - All those 75 years of age and over
4 - All those 70 years of age and over and clinically extremely vulnerable individuals
5 - All those 65 years of age and over
6 - All individuals aged 16 years to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality
7 - All those 60 years of age and over
8 - All those 55 years of age and over
9 - All those 50 years of age and over

We are currently vaccinating groups 1 and 2. We hope to be able to start vaccinating group 3 soon.

Due to the way the vaccines are made up we have to book appointments very quickly and flexibility by patients with this would be greatly appreciated.

Vaccinations are currently taking place at Shirebrook Leisure Centre (Park Road, Shirebrook, Mansfield, NG20 8JQ). If you have no way of travelling to this location please indicate below however we are still awaiting information on how and when we can vaccinate those who are completely housebound.

If you could respond on days/times in the next few weeks that you are unable to make we will avoid those days/times when offering you an appointment.

At this stage vaccine delivery is at short notice and we often only know a few days before that we will soon be receiving a delivery. We would greatly appreciate your understanding in this challenging time.


Would you like to have the vaccine? *


Can we text you with an appointment date/time? *
Are you able to travel to Shirebrook Leisure Centre? *
Have you or will you have any other (non-COVID) vaccinations? *
Have you had any immediate severe allergic reactions to medications or vaccinations? *
Have you had recent COVID symptoms or a positive COVID test? *

If we are able to offer you an appointment, we will contact you by email and/or text message as above. If we do not hear from you we will call when able.