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Coronavirus Vaccine Assessment Form

Please complete this form to help us update your medical record before your Coronavirus vaccine appointment is arranged.

This is not an appointment booking form. 

The purpose of this form is to update your record and gather your recent BMI calculation to see if you should be prioritised for a vaccine. 

This form is not compulsory.

We are just trying to gather information from patients that may not have been seen face to face or reviewed in the surgery since the pandemic started. 

You will be contacted by the Aneurin Bevan University Health Board or directly by ourselves when it is your turn to have the vaccine. Please be patient and avoid calling the surgery to ask us when you will be called. Thank you.

Coronavirus Vaccine Assessment Form
Only complete if you have allergies we need to be aware of
Must be completed to determine your BMI
Must be completed to determine your BMI

Thank you for completing the form

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All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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