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COVID-19 Vaccination Form

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COVID-19 Vaccination Form

Thank you for submitting your consent. Please consult with the pharmacist for the next steps.

"*" Indicates Required Fields

1. Patient Information

Full Name*

Medicare Number*

Individual Health Identifier (IHI) if applicable

Address*

Contact Phone Number

Date of Birth (DD/MM/YYYY)*

Gender

Your Email

Are you Aboriginal or Torres Strait Islander?*

Language spoken at home

Select Your Store*

2. Next of Kin (in case of emergency)

Next of Kin Name

Next of Kin Phone Number

3. Pre-Vaccination Screening

Have you had an allergic reaction to a previous dose of a COVID-19 vaccine?*YesNo

Have you had anaphylaxis to another vaccine or medication?*YesNo

Have you had a serious adverse event, that following expert review was attributed to a previous dose of a COVID-19 vaccine?*YesNo

Do you have a mast cell disorder?*YesNo

Have you had COVID-19 before?*YesNo

Do you have a bleeding disorder?*YesNo

Do you take any medicine to thin your blood (an anticoagulant therapy)?*YesNo

Do you have a weakened immune system (immunocompromised)?*YesNo

Are you pregnant?*YesNo

Have you been sick with a cough, sore throat, fever or are feeling sick in another way?*YesNo

Have you had a COVID-19 vaccination before?*YesNo

Have you received any other vaccination in the last 7 days?*YesNo

4. Relevant only for those receiving AstraZeneca COVID-19 Vaccine:

Have you ever been diagnosed with capillary leak syndrome?YesNo

Have you ever had major venous and/or arterial thrombosis in combination with thrombocytopenia, including diagnosed Thrombotic Thrombocytopenic Syndrome (TTS), following a previous dose of a COVID-19 vaccine?YesNo

Have you ever had cerebral venous sinus thrombosis?YesNo

Have you ever had heparin-induced thrombocytopenia?YesNo

Have you ever had blood clots in the abdominal veins (splanchnic veins)?YesNo

Have you ever had antiphospholipid syndrome associated with blood clots?YesNo

Are you under 60 years of age?YesNo

5. Relevant only for those receiving Pfizer or Moderna COVID-19 Vaccine:

Have you been diagnosed with myocarditis and/or pericarditis that is attributed to a previous dose of Pfizer or Moderna?YesNo

Have you had myocarditis, pericarditis or endocarditis within the past six months?YesNo

Do you currently have acute rheumatic fever or acute rheumatic heart disease?YesNo

Do you have severe heart failure?YesNo

If you answered yes to any of the above questions, you may still be able to receive Pfizer or Moderna, however you should talk to your GP, immunisation specialist or cardiologist first to discuss the best timing of vaccination and whether any additional precautions are needed.

6. Pharmacist use only

Dose 1

Date vaccine administered

Time received

COVID-19 vaccine brand administered

Batch no

Injection site

Pharmacist name

Dose 2

Date vaccine administered

Time received

COVID-19 vaccine brand administered

Batch no

Injection site

Pharmacist name

Please read information sheet on AstraZeneca to help with your decision:

https://www.health.gov.au/resources/publications/covid-19-vaccination-information-on-covid-19-astrazeneca-vaccine

Please read information on Vaxzevria (AstraZeneca) vaccine and thrombosis with thrombocytopenia:

https://www.health.gov.au/our-work/covid-19-vaccines/advice-for-providers/clinical-guidance/tts

Please read what to do after you are vaccinated for COVID-19, including how to get your vaccination certificate, what you need to do to stay safe and what to do if you have side effects:

https://www.health.gov.au/our-work/covid-19-vaccines/getting-your-vaccination/after

If you are a patient’s guardian or substitute decision-maker.

I am the patient’s legal guardian or substitute decision maker, and agree to COVID-19 vaccination of the patient named above

Guardian/substitute

6. Consent to receive COVID-19 vaccine

I confirm I have received and understood information provided to me on COVID-19 Vaccination. I confirm that none of the conditions above apply, or I have discussed these and/or any other special circumstances with my regular health care provider and/or vaccination service provider. I agree to receive a course of COVID-19 vaccine (two doses of the same vaccine) or chosen Booster shot. If I am signing on behalf of someone as a guardian than I Am Legally Authorised To Provide Consent On Behalf Of The Person Being Vaccinated. I Will Ask The Immuniser Before I Am Immunised. I Understand I Must Remain Within The Pharmacy Premises For A Period Of 20 Minutes Post Vaccination For Observation And So That I May Receive Additional Medical Attention, Including Emergency Care If Needed. I Consent To A Copy Of My Statement Of Immunisation Being Provided To the AIR.

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