Deansgrange
Medical Centre

General practice

COVID VACCINATION FORM FOR HIGH RISK PATIENTS AT DMC

Covid Vaccine High Risk Group Contact form

I am aged 59 years or younger

Please detail the medical condition(s) that put you at high risk:

Diabetes: type 1 or 2

Obesity: BMI >35

Chronic Respiratory Disease: such as COAD, pulmonary fibrosis, bronchiectasis, sarcoidosis, severe Asthma only (ie: asthma which requires continuous or repeated use of systemic corticosteroids, monoclonal antibody therapy, repeated exacerbations or needing hospital admissions in the past 12 months.)

Prader Willi Syndrome

Sickle Cell Disease

Cancer: undergoing active treatment, active disease in last year (all cancers), active disease in last 5 years (haematological cancer only)

Chronic Heart/ Vascular Disease

Chronic Kidney Disease eGFR <30

Chronic Liver Disease: such as cirrhosis, fibrosis, hepatitis, haemachromatosis with liver damage

Chronic Neurological Disase- which compromises respiratory function and/or the ability to clear secretions

Immunocompromised -due to disease or treatment: ie: transplant patients, those living with HIV, those on immunosuppressive medications such as high dose systemic steroids

Inherited Metabolic Disorder

Intellectual Disability

Severe Mental Illness

Thanks for submitting!