Housebound questionnaire for COVID-19 immunisations

DO NOT USE | This service is not live, and must not be used with real patients. If this is incorrect, please email [email protected].

IF YOU DON’T WANT TO USE THE ONLINE SERVICE | You can call the Central Booking Team on 0116 497 5700 between Monday – Saturday 09:00 – 15:00 if you would rather speak to a person.

Step 1 of 8

Hidden

pathway Optional

Hidden

referralID Optional

Hidden

token Optional

We need to confirm your details

This 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 birth

Name

First Last

Date of birth

Please confirm your postcode

Postcode

Are you able to leave your home to travel to a vaccination clinc?

Yes

Do you wish to be vaccinated against coronavirus? (COVID-19)

Do you wish to be vaccinated for coronavirus? (COVID-19)

Yes

Why don't you want to be vaccinated against coronavirus (COVID-19)? Optional

Would you like to speak to a clinician about the vaccine?

Yes

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 on

You 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