COVID Vaccination Appointment Request

This is a request for a COVID-19 vaccination form, we will be strictly following national and local guidance as to which age and clinically “at risk” groups are currently being vaccinated.

COVID-19 vaccinations are being administered from designated centres:

  • Lionwood Medical Practice, Wellesley Avenue North, NR1 4NR
  • Gurney Surgery, 40 Fishergatre, NR3 1SE
  • Bowthorpe Medical Centre, Wendene, Costessey, NR5 9HA

Please wear a face covering when attending the appointment. Do not attend if you are unwell or have COVID-19 symptoms.

Please do try and keep to your allocated time slot.

COVID Vaccination Request



This is for patients registered with Prospect Medical Practice.


This is for a COVID-19 vaccination. Covid-19 vaccination clinics are run on Monday to Saturday.
Please tick which vaccination centres you could get to:
Please tick which days you could attend for a vaccination:
Please specify your preferred time:


Please specify the ethnic group you consider you belong to: *

Terms and Conditions