COVID-19 Vaccination Referral Form

Email:		
Specialty:		

NHSGGC: Return form to ggc.covidvaccinationcontactcentre@ggc.scot.nhs.uk
Please insert patient name & CHI in subject heading.   One email per patient.

Date of Referral:

Referring Clinician Name:			
Responsible Consultant/GP:			
Referring Hospital/ GP Practice:			
Patient Name:		
CHI:		
Telephone Number:		

Reason for Vaccine Priority (Please do not refer if already on priority groups 4 or 6)	
•	Awaiting Transplant:	☐	
•	Commencing Immunosuppressive Therapy:	☐	
•	High risk Haematology patients not already on	☐	
groups 4 or 6		
•	Other …	 	_	
If new treatment/surgery, anticipated start date:		
Need for second dose before 12 weeks? Preferred timeframe (eg. 3/4 weeks)?	YES ☐	NO ☐	
If contacting to expedite second dose only:	
•	Date of first dose:	 	
•	Preferred timeframe for second dose	
 	weeks	

Any other comment:	
	
Please note that you should send your referral for vaccination to the Health Board of your patient’s residence rather than where the person is attending for clinical care