eVacc | Order Form
Thank you for choosing to use Eva Health's eVacc solution for your vaccination clinics.
NOTE: You will need to complete a form for each PCN site.
This form acts as a confirmation that you are requesting services from Eva Health, which are free for NHS-funded, GP-led clinics (as they will be paid for by NHS Digital).
At this stage, we need you to:
* Provide basic information about your clinic / site
* Confirm the scope of services to be delivered by Eva Health
* Confirm you're content to proceed
Your email address will be requested at the end, which acts as a digital signature.
After completing this form, we'll be in touch with next steps to get you started!
if you need anything from us in the meantime please email
Sign in to Google
to save your progress.
(as a person with suitable authority to instruct us on behalf of your clinic / vaccination site)
I'm ordering on behalf of...
Tick all that apply
We are vaccinating the following...
Tick all that apply
Phase 2 Covid
Phase 3 Covid / Boosters
Vaccination Site Name
ORIGINAL Vaccination Site ODS Code
Please state the first ODS Code you used to set up your vaccination site. This might be different from the latest one you use with Pinnacle.
Which of the following best describes your desired vaccination model
LVS + GP Practice
GP Practice only
Preferred go-live date
This is the first day you will administer jabs in eVacc, not when you want implementation to start. Please note NHS Digital requires 7 days' notice before going live
Eva Health - eVacc Services
The services relates to the eVacc point-of-care solution - this solution can be used to record Covid vaccinations. The service is accessed via the internet, and is cloud hosted by Eva Health. The services has been designed to adhere to NHS Digital's specifications.
There are no hardware products or services included (eg, laptops, barcode scanners etc).
Type of service delivered at your clinic
NHS funded - PCN delivered vaccination service
NHS funded - National Vaccination Programme service
Privately funded service
Agreement to start using eVacc
I confirm that I, on behalf of my vaccination site, want to proceed to use eVacc as my site(s)' point of care solution for vaccinations.
Additional notes / comments
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of Eva Health.