Consent Form for COVID-19 Vaccination - Comirnaty ( Pfizer ) Have you had an allergic reaction to a previous dose of a COVID-19 vaccine?YesNoHave you had anaphylaxis to another vaccine or medication?YesNoHave you had a serious adverse event, that following expert review was attributed to a previous dose of COVID-19 vaccine?YesNoHave you ever had mastocytosis which has caused recurrent anaphylaxis?YesNoHave you had COVID-19 before?YesNoDo you a bleeding disorder?YesNoDo you take any medicine to thin your blood (an anticoagulant therapy)?YesNoAre you pregnant?**YesNoDo you have a weakened immune system (immunocompromised)?YesNoHave you been sick with a cough, sore throat, fever or are you feeling sick in another way?*YesNoHave you had a COVID-19 vaccination before?*YesNoHave you received any other vaccination in the last 7 days?YesNoRelevant for those receiving Comirnaty only:Have you ever had myocarditis or pericarditis?*YesNoDo you currently have, or have you recently had acute rheumatic fever or endocarditis?*YesNoDo you have congenital heart disease?*YesNoFor people under 30 years of age: do you have dilated cardiomyopathy?*YesNoDo you have severe heart failure?*YesNoAre you a recipient of a heart transplant?*YesNoANY 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* Date Format: 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* Date Format: DD slash MM slash YYYY Make an appointment todayBOOK ONLINE OR CALL OUR FRIENDLY TEAM TO BOOKBOOK ONLINE CALL 02 4953 0966
