Dear Colleague,
Please complete this form if your practice does not provide NHS services and you or your staff are not registered to receive a Covid-19 vaccination through another organisation such as a Local Optical Committee (LOC) or direct with a Clinical Commissioning Group (CCG) or Primary Care Network (PCN).

This form has been designed to accommodate details of up to 15 staff members. If your practice employs more than 15 staff please contact LOCSU via

LOCSU will pass on your details to the LOC to be included in the local processes for collating the Covid-19 vaccine response for frontline healthcare staff in your area. They will contact you directly using the contact details provided below.

This process is not to be used by the general public. Separate NHS programmes are delivering these, and will contact people when it is their turn to get vaccinated.

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* 1. Practice name

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* 3. Your details

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* 4. Would you like to add another member of staff?