COVID-19 Booster Vaccine Registration Register for a COVID_19 Booster Vaccine Please enable JavaScript in your browser to complete this form.Please enter your PPSN *What is your age? *Have you had a serious allergic reaction (anaphylaxis) that needed medical treatment: I) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine, OR II) to any of the vaccine ingredients, including polyethylene glycol known as PEG? *YesNoHave you ever had a serious allergic reaction (anaphylaxis) to Trometamol (a contrast dye used in MRI radiological studies)? *YesNoHave you ever had a serious allergic reaction (anaphylaxis): I) after taking multiple different medications, with no reason known for the reaction. OR II) after having a vaccine or a medicine that contains polyethylene glycol (PEG), OR III) for unexplained reasons? *YesNoHave you ever had Mastocytosis (rare condition caused by an excess number of mast cells gathering in the body's tissues) OR II) idiopathic anaphylaxis. This is a condition diagnosed by an immunologist. OR III) a serious allergic reaction (anaphylaxis) due to food, medication or venom from an insect or animal? *YesNoHave you ever had myocarditis (inflammation of the heart muscle) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine? *YesNoHave you ever had pericarditis (inflammation of the lining around the heart) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine? *YesNoIf you answered yes on the previous question and had pericarditis (inflammation of the lining around the heart) after a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine, has your COVID-19 vaccination been approved by a specialist doctor? *YesNoN/AHave you been tested positive (with a PCR test) in the last 6 months for COVID-19 since you were fully vaccinated with a course of COVID-19 vaccine? *YesNoDo you have a bleeding disorder or are you on anticoagulation therapy? *YesNoHave you already received an additional dose or booster dose (after your initial primary vaccination course) in the last 3 months? *YesNoAre you pregnant? *YesNoDo you consent to vaccination with COVID-19 Booster Vaccine? *YesNoName *FirstLastEmail *Phone Number *Date Of Birth *Submit