Consent - Edgeworth Family Practice

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*

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*

Consent Form for COVID-19 Vaccination - Comirnaty ( Pfizer )

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