COVID-19 Vaccination Form - Choice Pharmacy

1. Patient Information

Full Name*

Medicare Number

Individual Health Identifier (IHI) if applicable

Address

Contact Phone Number

Date of Birth

Gender

Your Email

Are you Aboriginal or torres Strait Islander

Language spoken at home

Select Your Store

2. Next of Kin (in case of emmergency)

Next of Kin Name

Next of Kin Phone Number

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

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

Have you had anaphylaxis to another vaccine or medication?

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

Do you have a mast cell disorder?

Have you had COVID-19 before?

Do you have a bleeding disorder?

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

Do you have a weakened immune system (immunocompromised)?

Are you pregnant?

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

Have you had a COVID-19 vaccination before?

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

4. Relevant only for receiving AstraZeneca COVID-19 Vaccine

Have you ever been diagnosed with capillary leak syndrome?

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?

Have you ever had cerebral venous sinus thrombosis?

Have you ever had heparin-induced thrombocytopenia?

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

Have you ever had antiphospholipid syndrome associated with blood clots?

Are you under 60 years of age?

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?

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

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

Do you have severe heart failure?

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

Guardian/substitute decision-maker’s name

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 the facts relating to weighing up the potential benefits of the vaccine.

https://www.health.gov.au/resources/publications/covid-19-vaccination-weighing-up-the-potential-benefits-against-risk-of-harm-from-covid-19-vaccine-astrazeneca

please read information on thrombosis with thrombocytopenia

https://www.health.gov.au/resources/publications/patient-information-sheet-on-astrazeneca-covid-19-vaccine-and-thrombosis-with-thrombocytopenia-syndrome-tts

please read on potential side effects after taking your vaccination

https://www.health.gov.au/resources/publications/covid-19-vaccination-side-effects-you-might-have-after-your-vaccination-easy-read

Consent to receive immunisation

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.

Sign above the line

Submit my Authorisation