COVID-19 Vaccination Form


We have contacted those in Group 1 to 9 inviting them to book an appointment for their COVID-19 vaccination, but we are aware that there are some of you that may not have received an invite, possibly because the contact information that we have for you is incorrect. Please complete the following form that will enable us to update our records, we will then send out an appointment letter.

Please complete this form if you are:
  • a person over 16 who lives with individuals with severely weakened immune systems
  • aged 40 or over and not received an invite
  • aged 16 years to 64 years with certain underlying health conditions

We would advise you to check that your contact information including your most recent address, is up to date with you health care provider. 

GDPR and privacy information
Your information will be retained in a safe and secure manner in line with Data Protection Act 2018 and General Data Protection Regulation (GDPR). We are collecting personal data for the sole purpose of being able to provide you with an invitation to book your COVID-19 vaccination. We will not use this information for any other purpose other than is intended. The information will be processed by the Health Board's vaccination bookings team.

Privacy and fair processing notices:

Full Name *


Date of birth (DD/MM/YYYY) *


First line of address *


County *


Postcode *


Phone number *


GP practice name *