COVID-19 Vaccination Form

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

1. Patient Information

2. Next of Kin (in case of emmergency)

3.Please indicate if you or the person to be vaccinated

4. Relevant only for receiving AstraZeneca COVID-19 Vaccine

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

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.

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

6. Pharmacist use only

Dose 1

Dose 2

Consent to receive immunisation

Sign above the line
Choice Pharmacy