1. Which of our branches will you be visiting? —Please choose an option—Atherton (760 Atherton Road, Hindley Green, WN2 4SB)Barnton (76 Runcorn Road, Northwich, CW8 4EY)Blackrod (28 Blackhorse Street, Bolton, BL6 5EW)Bradlegh (Newton-le-Willows Community Hospital, WA12 8RB)Clayton (Kingsbridge Avenue, Newcastle-under-Lyme, ST5 3HP)Garswood (Garswood Health Centre, WN4 0XD)Heatons (23 Bassenthwaite Avenue, Moss Bank, WA11 7AB)Ince Green (7 Ince Green Lane, Higher Ince, WN2 2AR)Market (45 Brackley Street, Farnworth, BL4 9DS)Mesnes (13 Mesnes Street, Wigan Town Centre, WN1 1QP)Millfields (2 Millfields Court, Eccleston, WA10 5RG)Moorside (Aspull Health and Wellbeing Clinic, WN2 1XH)Sale (69 Washway Road, Sale, M33 7SS)Taylors (210 West End Road, Haydock, WA11 0AN)Village (23 Green Lane, Ashton-on-Mersey, M33 5PN)West Street (145 West Street, Crewe, CW1 3HH)

To find your nearest branch, please visit: Branch Finder

2. NHS Number (If Known)

3. Date of Birth

4. First Name

5. Last Name

6. Postcode

7. Email address

8. Mobile number

9. Which services are you booking for?

COVID-19FluCOVID-19 and Flu

10. Eligibility for the COVID-19 vaccination —Please choose an option—Aged 65 years and overImmunosuppressedLiving in a care home for older adultsYounger adults in long-stay nursing and residential care settingsPregnantChronic Respiratory Disease (E.g. COPD)Chronic Heart Disease and Vascular Disease (E.g. Chronic Heart Failure)Chronic Kidney Disease - Stages 3, 4 or 5Chronic Liver DiseaseChronic Neurological Disease (E.g. Stroke)DiabetesAddison's DiseaseSpleen Removed or Dysfunction with Spleen (e.g. Sickle Cell Anaemia)Morbid Obesity (BMI≥40)Severe Mental IllnessNot Eligible - I want to pay for a private vaccineOther

11. Eligibility for the Flu vaccination —Please choose an option—Aged 65 years and overPregnantFrontline Health & Social care workerResident in a long-stay residential care homeThe main carer for an older or disabled person, or receive a carer's allowanceImmunosuppressedClose contact of people with immunosuppressionChronic respiratory diseaseChronic heart disease (e.g. Heart Failure)Chronic kidney diseaseChronic liver diseaseChronic neurological disease (e.g. Stroke)DiabetesAddison's DiseaseSpleen Removed or splenic dysfunction (e.g. Sickle Cell Disease)Morbidly Obese (BMI ≥40)Learning disabilityEmployed through direct payment or personal health budgetNot Eligible - I want to pay for a private vaccineOther

12. Are you or could you be pregnant?

YesNoOther

13. Preferred Date between 3rd-31st OCTOBER

14. Preferred Time Slot

• 09:30-10:30

• 10:30-11:30

• 11:30-12:30

• 15:00-16:00

• 16:00-17:00