Covid Vaccination for HIGH RISK patients (Group 4)

The HSE has advised that patients aged 16 to 64 years that are at HIGH RISK of complications following Covid infection are offered vaccination as our next priority.

https://www2.hse.ie/screening-and-vaccinations/covid-19-vaccine/rollout/rollout.html#group7

This form is to help us identify patients in this group who we will contact and offer vaccination.

Who should SUBMIT this form?

  • Patients who meet the criteria below and have not yet received a vaccine.
  • Patients who meet the criteria below and have not yet been listed for vaccination by their GP.

Who should NOT submit this form?

  • Patients who do not meet any of the criteria listed.
  • Patients who have already received Covid vaccination.
  • Patients who have already been listed for vaccination with a hospital or their GP.

Forms submitted will be reviewed and only patients identified as HIGH RISK will be offered vaccination at this time. Other patient groups will be contacted later as per HSE guidelines.

High Risk Vaccination Registration Form

Irish mobile numbers only, please.










Please check ALL relevant boxes

**BMI >35 eg 5'2"@ 85kg / 5'5"@ 95kg / 5'8"@ 104kg / 5'11" 113@kg