Maternity | Vaccinations in pregnancy

First name Required

Last name Required

Title

Date of birth Required

NHS / hospital number Required

Due date identified by ultrasound / scan Required

Phone number Required

Email address Required

Home postcode Required

I consent for use of email to confirm appointment Required

Do you have any allergies? Required

Yes

No

If yes, what are you allergic to?

Have you had a reaction to any vaccines before? Required

Yes

No

If yes, please explain what happened

Which vaccination would you like? Required

Whooping cough (Pertussis) - from 16 weeks pregnant

Respiratory Syncytial Virus (RSV) - from 28 weeks pregnant

All of the above

Which day / time would you prefer to have your vaccination(s)? Required

Wednesday 09:15 - 11:00

Wednesday 11:00 - 12:00

Wednesday 13:00 - 14:30

Wednesday 14:30 - 15:45

Saturday 09:15 - 11:00

Saturday 11:00 - 12:00

Saturday 13:00 - 14:30

Saturday 14:30 - 15:45

Do you require an interpreter? Required

Yes

No

If Yes, please confirm which language service you require:

Any additional information / questions. *Please include any dates in particular when you are not available e.g. holiday*

Vaccination self-referral form