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

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

5. Pharmacist use only

Dose 1

Dose 2

Consent to receive immunisation

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