Patient COVID-19 Vaccine Registration Form

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Personal Information

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Select your allocation group

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In order to provide your care we need to collect sensible personal and medical information. We recognise the importance of protecting data personal medical records in all that we do, and take care to meet our legal and other duties, including compliance with relevant law, Medical Council regulations and guidance. Under the General Data Protection Regulation (GDPR) Central Park Medical is obliged to ensure patient data, supplied as part of the patient process.

I agree that my personal details could be and will be used for medical purposes. I confirm that all the information I provided is correct.

1.The COVID-19 Vaccine Allocation Strategy sets out a provisional priority list of groups forvaccination once a safe and effective vaccine(s) has received authorisation from theEuropean Medicines Agency (EMA).The Strategy was developed by the NationalImmunisation Advisory Committee (NIAC) and Department of Health, endorsed by theNational Public Health Emergency Team (NPHET), and approved by Government on 8December 2020.The Strategy is a further component to the State’s response to theCOVID-19 pandemic, and will evolve and adapt with more detailed information on thevaccines and their effectiveness.

2.Chronic heart disease, including hypertension with cardiac involvement; chronic respiratorydisease, including asthma requiring continuous or repeated use of systemic steroids or withprevious exacerbations requiring hospital admission; Type 1 and 2 diabetes; chronicneurological disease; chronic kidney disease; body mass index >40; immunosuppression dueto disease or treatment; chronic liver disease; cancer; down syndrome; history of organtransplant; sickle cell disease

Thanks for submitting!