Mon - Fri: 9am - 7pm Sat: 9am - 6pm

   020 8654 1149  215 Lower Addiscombe Rd, Croydon CR0 6RB

Private Vaccination Assessment

Please complete this form before your appointment. This allows our pharmacist to review your medical history and ensure the selected vaccination is safe and suitable for you.

*This is a private prescribing service. Consultation and treatment fees may apply.

How Our Private Vaccination Service Works At Larchwood Pharmacy

1. Complete an Online Assessment

Start by filling out a secure online eligibility form. This allows us to review your medical history and determine whether the service may be suitable for you.

2. Attend Your In-Pharmacy Consultation

If eligible, you’ll be invited to Larchwood Pharmacy for a private consultation with our prescribing pharmacist to discuss your health, goals and treatment options.

3. Receive your vaccination

If clinically appropriate, treatment will begin with structured guidance, ongoing monitoring and continued pharmacist support.

Private Vaccination Questionnaire

Private Vaccination Questionnaire

Please complete this form prior to your vaccination appointment so our pharmacist can assess your suitability for the vaccine.

Personal Details

Please provide accurate personal details. This information allows us to verify your identity, assess vaccination suitability and communicate safely regarding your treatment.

All information is handled confidentially in accordance with UK data protection regulations.

Vaccine Requested

Medical History

Please select any conditions that apply to you, past or present. This helps our pharmacist understand your overall health.

Current Medication

Allergies

Previous Vaccine Reactions

Pregnancy & Reproductive Health

These questions help us understand whether treatment is appropriate based on your current or planned pregnancy status.

Informed Consent

I confirm that the information provided is accurate and complete.

Book Free Consultation