VACCINE REGISTRATION FORM

The Covid-19 vaccine will be available to all persons that reside in the Turks and Caicos Islands from 25 January 2021 onwards.  Our aim is to make the vaccine available to as many as want it.  All persons who wish to take the vaccination (at present, 2 x immunizations of the Pfizer Vaccine, 21 days apart) are asked to provide the information below. A limited number of fields are mandatory, the more information you can give though the better.

If you have already been provided with an appointment you need not register. Access to the information provided will only be accessible to a small number of healthcare professionals working on the roll out of the vaccine and will not be shared with any other TCIG department or private enterprise. Clinical vulnerability and aggregated risk factors such as age and occupation will be utilised for prioritisation purposes. By completing the survey, individuals will receive updates on COVID-19 vaccine availability, including appointment scheduling in due course.

The administration of the Covid-19 vaccine will be prioritised to specific groups in order to protect those who are most vulnerable i.e. the elderly, those with chronic underlying medical conditions and front-line workers. Subsequently, the vaccine will be offered to all members of the public residing in the Turks and Caicos Islands to protect against Covid-19.

Note: Information for recipients is available here.

Gender*

Male

Female

Are you a resident of the Islands? *

Yes

Are you registered with the National Health Insurance Plan? *

Yes

National Health Insurance Plan Number*

Are you registered with the National Insurance Board *

Yes

National Insurance Board Number*

E-mail confirmation*

Do you have any chronic conditions?* For example:

Cancer
Chronic kidney disease
Chronic lung disease
Down Syndrome
Heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies
Immunocompromised state (weakened immune system) from solid organ transplant
Very overweight or obese
Sickle cell disease
Type 2 diabetes mellitus

Yes

Are you taking any current medication(s)*

Yes

Please list your current medications*

Do you have any allergies?*

Yes

Please list your known allergies*

Have you previously been diagnosed with COVID-19?*

Yes

Please provide further details* (date of diagnosis, were you hospitalized, treatment etc.)

Please provide the date that you were COVID-19 diagnosed*

Are you pregnant / breast feeding or are you likely to be pregnant soon? *

Yes

Have you been referred by a registered Doctor?

Yes

Are you registered with a Private Medical Practice?*

Yes

Please state the name of medical practitioner*

Please state the name of your primary healthcare clinic*

Please provide contact details for your primary healthcare clinic

Consent; I have reviewed the information pertaining to the vaccine and understand the benefits and potential risk of taking the vaccine.

I commit to ensuring that I take the two doses as required within the specified time frame in order for the vaccine be effective.

Please note that the vaccine will not be fully effective until one week after the second dose is administered and all persons will still be required to wear face coverings, practice social distancing and comply with the other public health requirements.