FREE Covid Vaccination Request for ANYONE
WE ARE OPEN FOR COVID VACCINATIONS MONDAY TO FRIDAY 9AM TO 5PM. SATURDAYS 9:30AM TO 12PM.

If you are an enrolled patient, you can also ring us to book an appointment on 5702999 or fill out this form after hours.

For anyone else who is not enrolled please complete this form. We will ring you back to arrange an appointment.

You can book your COVID-19 vaccination now if you are eligible.

PLEASE READ THE INSTRUCTIONS:

1. We will call back to arrange a suitable time. Please let us know if you are coming in with anyone else who is having a Covid vaccine as well.

2. If you have any symptoms of cough, sore throat, runny nose, loss of smell, fever or shortness of breath, OR have been a close contact on in a location of interest within the last 2 weeks. You will have to defer your vaccine.

3. When arriving for your appointment please park in the car parks BEFORE the traffic cones.

4. STAY in your car. Ring reception to advise you are here on 09-5702999.

5. Please read the Privacy Statement
https://covid19.govt.nz/assets/resources/Vaccine-resources/COVID-19-vaccines_privacy-statement.pdf

6. Please read this information about getting your vaccine.
https://covid19.govt.nz/assets/resources/Vaccine-resources/COVID-19-vaccines-what-to-expect.pdf

7. You will receive a call when we are ready for you and make your way to the front door of the practice and knock on the door.

For more information on the vaccine please see below:-
https://covid19.govt.nz/covid-19-vaccines/get-the-facts-about-covid-19-vaccination/covid-19-vaccine-resources/covid-19-vaccine-fact-sheets/
Email *
Please provide preferred date of vaccination. *
We will call you to arrange a time on that date.
Who are you filling this form out for? *
If other, it has to be with their consent.
Surname *
First name *
Sex *
Date of birth *
MM
/
DD
/
YYYY
Mobile phone number *
Are you an enrolled patient of Mt Wellington Family Health Centre? *
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