First Name *Last Name *Email *Date of Birth *Date of Birth - This is to determine vulnerability by age group. Input is minimum restricted. Select Year then Month then DayCoVId-19 App *YesNoHave you downloaded the Covid-19 app to your phone?2020 Flu Shot *YesNoHave you had the 2020 flu shot? Are you UNDER 70 years of Age *Yes No (but I accept any risk)Please be advised that over 70's proceed at their own riskCoVid-19 Contact *YesNoCan you confirm that you have NOT been in contact or worked with someone infected with Covid-19? Covid-19 Contact Details Suspected ContactVulnerability *YesNoCan you confirm that you DO NOT have a chronic illness or immune deficiency? Chronic Illnesss Do you have a chronic illness or immune deficiency? NameSubmit
