Consent Form for Vaccination

Please complete this online form prior to your attendance.
If preferred, paper based forms are available at the clinic.
Please refresh the page if you receive a 'Validation Error' after submission; you will not lose information already entered.

Your Name (required)

Date of Birth (required, any format)

Your Email (optional - for an emailed copy of your answers)

Are you Aboriginal and/or Torres Strait Islander?
 Aboriginal only Torres Strait Islander only Aboriginal & Torres Strait Islander No Prefer not to answer

Please answer each of the following Questions
(if you are uncertain of any answer, please tick 'Yes' and give details)

Have you had an allergic reaction to a previous dose of a COVID-19 vaccine?
 No Yes (give details)

Have you had anaphylaxis to another vaccine or medication?
 No Yes (give details)

Have you had a serious adverse event, that following expert review was attributed to a previous dose of a COVID-19 vaccine (& did not have another cause identified)?
 No Yes (give details)

Have you recurrently suffered from anaphylaxis due to the diagnosis of 'mastocytosis'?
 No Yes (give details)

Have you tested positive for COVID-19 before?
 No Yes (give details)

Do you have a bleeding disorder?
 No Yes (give details)

Do you take any medicine to thin your blood (an anticoagulant therapy)?
 No Yes (give details)

Do you have a weakened immune system (immunocompromised)?
 No Yes (give details)

Are you pregnant?
 No/not relevant Yes (give details)

Are you currently feeling sick with a cough, sore throat, fever or in another way?
 No Yes (give details)

Which of the available COVID-19 vaccination(s) have you previously received?
 Pfizer Astra Zeneca Moderna None Other/not sure/I have more information:

Have you been diagnosed with myocarditis and/or pericarditis after either the Pfizer or Moderna vaccines?
 No Yes (give details)

Have you had myocarditis or pericarditis within the past three months?
 No Yes (give details)

Do you currently have acute rheumatic fever or acute rheumatic heart disease?
 No Yes (give details)

Do you have severe heart failure?
 No Yes (give details)

Please alert either us or your regular health care provider if you have any side effects after vaccination that you are worried about.

Despite being vaccinated, you may still become infected with COVID-19.
This is not a complication of the vaccination and you must still follow all public health advice in your state or territory to stop the spread of COVID-19, including:
• keeping your distance – stay at least 1.5 metres away from others
• washing your hands often with soap and water, or using hand sanitiser
• wearing a mask
• minimising the time shared in unventilated areas with others (outdoors is preferable)
• staying home if you are unwell with cold or flu-like symptoms and arranging to get a COVID-19 test.

Your vaccination will be recorded on the Australian Immunisation Register.
You can view your vaccination record online through your (links open in a new page):
Medicare Express App
MyGov Account - Australian Government
My Health Record Account

Next of kin (in case of emergency)

Relationship of next of kin & their contact #

Any other information you wish to state

Formal Consent

I confirm I have received and understood information provided to me about COVID-19 vaccination.

I confirm that I have none of the above conditions apply to me, or I have discussed these conditions and any other special circumstances with my regular health care provider and/or vaccination provider.

I agree to receive a course of COVID-19 vaccine / I agree to receive a booster of COVID-19 vaccine

I (append name) am the patient’s parent, guardian or substitute decision-maker, and agree to COVID-19 vaccination of the patient named above.