(091) 523 207 info@salthillpharmacy.ie

COVID-19 Booster Registration

Salthill Pharmacy is now taking registrations for the Pfizer / BioNTech COVID-19 Vaccine Booster.

The following is a list of those who are eligible to receive the Vaccine Booster at Salthill Pharmacy, in order of priority:

  • Over 60’s
  • Healthcare Workers
  • Those aged between 16 – 59 with underlying health conditions
  • Those aged between 50-59

The vaccine provided is from Pfizer:

The National Immunisation Advisory Committee (NIAC) has recommended this vaccine as a booster.

Further information on the vaccine booster and the underlying conditions covered are found on the HSE website.

    Questions of Eligibility

    Date of your last COVID-19 vaccination:

    Have you tested positive for COVID-19 in the last 2 months?

    What age range are you in?

    Have you received an additional dose or booster dose in the last three months?

    This form provides Salthill Pharmacy with the details required to process your vaccination registration. Do you understand that submitting your registration details does not automatically guarantee you an appointment?

    Your Personal Details

    Name:

    Date of Birth (DD / MM / YYYY):
    Day Month Year

    Mobile Number:

    Email:

    Address:

    Nationality*:

    PPSN* (If you have no PPS Number, enter "None"):

    Your Doctor's Information

    Doctor's Name:

    Doctor's Practice Name (Optional):

    Doctor's Phone number (Optional):

    Doctor's Address (Optional):

    COVID-19 Vaccination Questions

    Please answer the following questions. They will have a Yes or No answer.

    1. Have you ever had a serious allergic reaction (anaphylaxis) that needed medical treatment:
    I) after having a previous dose of the Pfizer / BioNTech (Comirnaty®) or Moderna (Spikevax®) COVID-19 vaccine, OR
    II) to any of the vaccine ingredients, including polyethylene glycol known as PEG?*

    2. Have you ever had a serious allergic reaction (anaphylaxis):
    I) after taking multiple different medications, with no reason known for the reaction. This may mean you are allergic to polyethylene glycol (PEG) OR
    II) after having a vaccine or a medicine that contains polyethylene glycol (PEG), OR
    III) for unexplained reasons. This may mean you are allergic to polyethylene glycol (PEG)?*

    3. Have you ever had:
    I) Mastocytosis (rare condition caused by an excess number of mast cells gathering in the bodys tissues) OR
    II) idiopathic anaphylaxis. This is a condition diagnosed by an immunologist. OR
    III) a serious allergic reaction (anaphylaxis) due to food, medication or venom from an insect or an animal?*

    4. Have you had myocarditis (inflammation of the heart muscle) after having a previous dose of the Pfizer / BioNTech or Moderna (Spikevax®) COVID-19 vaccine?*

    5. Have you had pericarditis (inflammation of the lining around the heart) after having a previous dose of the Pfizer / BioNTech or Moderna (Spikevax®) COVID-19 vaccine?*

    6. Do you have a bleeding disorder or are you on anticoagulation therapy?*

    If yes, you can still get a vaccine if you have a bleeding disorder or take anticoagulation medicines. Ensure you tell your vaccinator about your condition.