Full Name*
Medicare Number*
Individual Health Identifier (IHI) if applicable
Address*
Contact Phone Number
Date of Birth (DD/MM/YYYY)*
Gender—Please choose an option—MaleFemalePrefer not to say
Your Email
Are you Aboriginal or Torres Strait Islander?*—Please choose an option—Yes, Aboriginal onlyYes, Torres Straight Islander onlyYes Aboriginal and Torres Strait IslanderNo
Language spoken at home
Select Your Store*—Please choose an option—BomaderryBox HillBurwoodCameron parkColebeeEastern creekNorth KellyvilleShell CoveSilkstoneSpringfarmVincentia
Next of Kin Name
Next of Kin Phone Number
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
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
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.
Dose 1
Date vaccine administered
Time received
COVID-19 vaccine brand administered
Batch no
Injection site —Please choose an option—Left arm deltoidRight arm deltoid
Pharmacist name
Dose 2
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
I am the patient’s legal guardian or substitute decision maker, and agree to COVID-19 vaccination of the patient named above
Guardian/substitute
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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