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

    2. Next of Kin (in case of emergency)

    3. Pre-Vaccination Screening

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

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

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

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

    YesNo

    YesNo

    YesNo

    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

    Dose 2

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

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

    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:

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

    6. Consent to receive COVID-19 vaccine

    Sign above the line
    Submit my Authorisation
    Choice Pharmacy