Covid-19 vaccine Covid-19 vaccine Note: Questions marked by * are mandatory *This is a mandatory field. First name *This is a mandatory field. Surname *This is a mandatory field. Date of birth DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MM Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec *This is a mandatory field. Department / Ward *This is a mandatory field. Job Title I haven’t booked my jab yet because I had it at my GP/other provider I want the Astra Zeneca vaccine I want to wait and see if the Pfizer vaccine is safe I’m concerned because it was developed so quickly I was told I couldn’t have it before my flu jab I was told I couldn’t have it due a previous allergic reaction I don’t think the vaccine will be effective I don’t like needles I’m worried it will affect my fertility Hub times don’t work for me If none of the above reasons, please tell us why? * Spam Guard: What is the next number after 5? Write the number as a word.
