COVID Booster Vaccination Request

Please only fill this form out if your have been asked to do so by the surgery.

COVID booster vaccines can be given 180 days after the second dose. Patiens attending the surgery prior to this will not be able to have the booster vaccine and will be asked to rebook

For further information please see the PHE: COVID Booster Leaflet.

Please see the Flu and COVID Clinic Information to ensure you are prepared for your vaccine.

COVID Booster Vaccination Request



COVID booster vaccinations will be held at The Lanes Medical Centre.


If you are eligible for a flu vaccine, you will be offered a COVID Booster vaccine: COVID Booster Vaccine.

Please only complete this form if you have checked your eligibility or been asked by the surgery to do so.

Please choose which eligible group you fall into: *


Please choose your preferred date(s):
Please select your preference on 24th November:

Before attending your vaccination

Requesting Vaccination