Answer the housebound vaccination questionnaire Step 1 of 8 12% Hiddenpathway Optional HiddenreferralID Optional Hiddentoken Optional We need to confirm your detailsThis is an automated service on behalf of the Leicester, Leicestershire and Rutland Integrated Care Board, to assess whether you need to receive a vaccination at home. Before we can proceed, we need to check some details to make sure we are dealing with the right person. Please confirm your date of birthName First Last Date of birth DD slash MM slash YYYY Please confirm your postcodePostcode Are you able to leave your home to travel to a vaccination clinc? Yes No Do you wish to be vaccinated against coronavirus? (COVID-19)Do you wish to be vaccinated for coronavirus? (COVID-19) No Yes Why don't you want to be vaccinated against coronavirus (COVID-19)? OptionalWould you like to speak to a clinician about the vaccine? Yes No Please tell us any important information that we might need to know, for example, if it takes you a while to get to the door.Important information Optional If there is a trusted individual that you want us to contact, for example, to give us the code to a key safe at home, please tell us in the box below.Trusted individual details Optional Please choose a date to be vaccinated onYou will be contacted by text message with the appointment details.Please choose a date Monday 13th May 2024 – TEST CLINIC Tuesday 14th May 2024 – TEST CLINIC Wednesday 15th May 2024 – TEST CLINIC