Consent Form for COVID-19 Vaccination - Comirnaty ( Pfizer ) Have you had an allergic reaction to a previous dose of a COVID-19 vaccine? Yes No Have you had anaphylaxis to another vaccine or medication? Yes No Have you had a serious adverse event, that following expert review was attributed to a previous dose of COVID-19 vaccine? Yes No Have you ever had mastocytosis which has caused recurrent anaphylaxis? Yes No Have you had COVID-19 before? Yes No Do you a bleeding disorder? Yes No Do you take any medicine to thin your blood (an anticoagulant therapy)? Yes No Are you pregnant?** Yes No Do you have a weakened immune system (immunocompromised)? Yes No Have you been sick with a cough, sore throat, fever or are you feeling sick in another way?* Yes No Have you had a COVID-19 vaccination before?* Yes No Have you received any other vaccination in the last 7 days? Yes No Relevant for those receiving Comirnaty only:Have you ever had myocarditis or pericarditis?* Yes No Do you currently have, or have you recently had acute rheumatic fever or endocarditis?* Yes No Do you have congenital heart disease?* Yes No For people under 30 years of age: do you have dilated cardiomyopathy?* Yes No Do you have severe heart failure?* Yes No Are you a recipient of a heart transplant?* Yes No ANY QUESTIONS REGARDING THE COVID VACCINE PLEASE SPEAK WITH A YOUR REGULAR HEALTH PROFESSIONAL PRIOR TO YOUR APPOINTMENT * Cromiraty is the preferred vaccine for people in these groups but if not available, AstraZeneca COVID- 19 vaccine can be considered if the benefits of vaccination outweigh the risk.Consent to receive COVID-19 vaccine* 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 anyother 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) Patient’s name:* Patient's Signature*Patient's Email:* Date* DD slash MM slash YYYY I am the patients guardian/substitute decision-maker (Please enter details below), and agree to the COVID-19 vaccination of the patient named above I am the patients guardian/substitute decision-maker (Please enter details below), and agree to the COVID-19 vaccination of the patient named above Guardian/substitute decision-maker’s name:* Guardian/substitute decision maker’s signature:*Guardian/substitute decision maker’s email:* Date* DD slash MM slash YYYY Make an appointment todayBOOK ONLINE OR CALL OUR FRIENDLY TEAM TO BOOKBOOK ONLINE CALL 02 4953 0966
