COVID Vaccine Consent form | Aya Medical Centre

Consent form: AstraZeneca COVID-19 vaccination

Before completing this form, we recommend you read the information sheet on the COVID-19 Vaccine AstraZeneca on the Department of Health website www.health.gov.au.

Patient Information

People who have a COVID-19 vaccination have a much lower chance of getting sick from COVID-19. The COVID-19 vaccination is free, and you can choose whether to have the vaccination or not.

There are two brands of vaccine in use in Australia. Both are effective and safe. Comirnaty (Pfizer) vaccine is preferred over AstraZeneca COVID-19 vaccine for adults under 60 years of age.

You need to have two doses of the same brand of vaccine. Medical experts have studied COVID-19 vaccines to make sure they are safe. Most side effects are mild may tenderness, pain at the injection site, headache, fever, fatigue, malaise, joint and muscle pain. As with any vaccine or medicine, there may be rare and/or unknown side effects and last for 1-2 days

A very rare side effect of blood clotting (thrombosis) with low platelet levels (thrombocytopenia) has been reported following vaccination with AstraZeneca. This is not seen after the Comirnaty (Pfizer) vaccine.

For further information refer to the patient information sheets on ‘AstraZeneca COVID-19 vaccine and thrombosis and thrombocytopenia syndrome (TTS)’ and ‘Weighing up the potential benefits against risk of harm from COVID-19 Vaccine AstraZeneca’ on the Department of Health website.

Please contact healthcare provider if you have any side effects like a sore arm, headache, fever, body aches or any symptom that is unusual for you.

You will be asked to remain in the Medical Centre for 15 minutes observation after your vaccination, but if you have a previous history of anaphylaxis to a vaccine you will be required to wait for 30 minutes.

Some people may still get COVID-19 after vaccination, so you must still follow public health precautions as required in your State or Territory to stop the spread of COVID-19 including physical distancing, wearing a mask, enhanced personal hygiene (hand washing/sanitizing), staying at home if unwell with cold-like symptoms and promptly getting tested for COVID-19.

Vaccination providers record all vaccinations on the Australian Immunisation Register, as required by Australian Law. You can view this online in your Medicare/ MyGov/MyHealth Record account.

For information on how your personal details are collected, stored and used visit http://www.health.gov.au/covid19-vaccines.

On the day you receive your vaccine

Before you get vaccinated, tell the person giving you the vaccination if you:

have had an allergic reaction, particularly anaphylaxis (a severe allergic reaction) to a previous dose of a COVID-19 vaccine, to an ingredient of a COVID-19 vaccine, or to any other vaccines or
are immune-compromised. This means that you have a weakened immune system that may make it harder for you to fight infections and other

if you have a past history of cerebral venous sinus thrombosis (a type of brain clot) or heparin induced thrombocytopenia (a rare reaction to heparin treatment), idiopathic splanchnic (mesenteric, portal and splenic) venous thrombosis, or anti-phospholipid syndrome with thrombosis.

Consent form for COVID-19 vaccination

Pre-Vaccination Screening

Do you have any serious allergies, particularly anaphylaxis, to anything and specifically a COVID vaccine ingredient?*

Yes

Have you had anaphylaxis to another vaccine or medication?*

Yes

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

Yes

Have you ever had mastocytosis which has caused recurrent anaphylaxis?*

Yes

Have you had COVID-19 before?*

Yes

Do you have a bleeding disorder?*

Yes

Do you take any medicine to thin your blood (an anticoagulant therapy)? If so, which medication do you take?*

Yes

Medication Taken

Do you have a weakened immune system (immunocompromised)?*

Yes

Are you pregnant?*

Yes

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

Yes

Have you had a COVID-19 vaccination elsewhere?*

Yes

If so, when?

DD slash MM slash YYYY

And which one?

Astra Zeneca

Pfizer

Other

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

Yes

Have you ever fainted after a vaccination or are you especially scared of needles?*

Yes

Have you ever been diagnosed with capillary leak syndrome?*

Yes

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?*

Yes

Have you had cerebral venous sinus thrombosis (a type of brain clot) OR heparin induced thrombocytopenia (a rare reaction to heparin treatment) OR idiopathic splanchnic (mesenteric, portal and splenic) venous thrombosis OR anti- phospholipid syndrome with thrombosis in the past?*

Yes

Are you under 60 years of age?*

Yes

*Comirnaty (Pfizer) 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.

Please talk to your doctor if you have any questions or concerns before getting your COVID-19 vaccination.

Consent to receive COVID-19 vaccine

Consent*

I confirm I have received and understood information provided to me on Covid-19 AstraZeneca vaccination*

Consent*

I confirm that none of the conditions above apply, or I have discussed these and/or any other special circumstances with my regular healthcare provider and/or vaccination service provider*

Consent*

I agree to receive a Covid-19 AstraZeneca vaccine today*

Patient's Name

Date of Birth

DD slash MM slash YYYY

Email Address

Date

DD slash MM slash YYYY

Consent

I am the patient’s legal guardian or substitute decision maker, and agree to COVID-19 vaccination of the patient named above

Guardian/substitute

Date

DD slash MM slash YYYY

This field is for validation purposes and should be left unchanged.

Consent form: Comirnaty (Pfizer) COVID-19 vaccination

Before completing this form, we recommend you read the information sheet on the COMIRNATY (Pfizer) COVID-19 Vaccine on the Department of Health website www.health.gov.au.

Patient Information

People who have a COVID-19 vaccination have a much lower chance of getting sick from COVID-19. The COVID-19 vaccination is free for everyone, and you can choose whether to have the vaccination or not. There are two brands of vaccine in use in Australia. Both are effective and safe. Comirnaty (Pfizer) vaccine is preferred over AstraZeneca COVID-19 vaccine for adults under 60 years of age. You need to have two doses of the same brand of vaccine. The person giving you your vaccination will tell you when you need to have the second vaccination.

Medical experts have studied COVID-19 vaccines to make sure they are safe. The more common side effects may include tenderness or pain at the injection site, headache, fever, fatigue, malaise, joint and muscle pain. As with any vaccine or medicine, there may be rare and/or unknown side effects and last for 1-2 days

Cases of Myocarditis (inflammation of the heart muscle) and/or pericarditis (inflammation of the lining of the heart) have been reported as very rare side effects after mRNA COVID-19 vaccines (including Comirnaty (Pfizer)). Cases primarily occurred within 14 days after vaccination, more often in males aged under 30 years and after the second dose. COVID-19 Vaccine AstraZeneca is not associated with an increased risk of myocarditis/pericarditis.

Please contact your healthcare provider if you have any side effects like a sore arm, chest pain, heart palpitations, shortness of breath, headache, fever, body aches or any symptom that is unusual for you.

Vaccination providers record all vaccinations on the Australian Immunisation Register, as required by Australian Law. You can view this online in your Medicare/ MyGov/MyHealth Record account.

For information on how your personal details are collected, stored and used visit https://www.health.gov.au/covid19-vaccines

On the day you receive your vaccine

Before you get vaccinated, tell the person giving you the vaccination if you:

have had an allergic reaction, particularly anaphylaxis (a severe allergic reaction) to a previous dose of a COVID-19 vaccine, to an ingredient of a COVID-19 vaccine, or to any other vaccines or
are immune compromised This means that you have a weakened immune system that may make it harder for you to fight infections and other

if you have a history of inflammatory cardiac illness (e.g. pericarditis, myocarditis, endocarditis), acute rheumatic fever, dilated cardiomyopathy (for people under 30 years of age), congenital heart disease, severe heart failure or if you are a heart transplant recipient.

Consent form for COVID-19 vaccination

Pre-Vaccination Screening

Do you have any serious allergies, particularly anaphylaxis, to anything and specifically a COVID vaccine ingredient?*

Yes

Have you had anaphylaxis to another vaccine or medication?*

Yes

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

Yes

Have you ever had mastocytosis which has caused recurrent anaphylaxis?*

Yes

Have you had COVID-19 before?*

Yes

Do you have a bleeding disorder?*

Yes

Do you take any medicine to thin your blood (an anticoagulant therapy)? If so, which medication do you take?*

Yes

Medication Taken

Do you have a weakened immune system (immunocompromised)?*

Yes

Are you pregnant?*

Yes

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

Yes

Have you had a COVID-19 vaccination elsewhere?*

Yes

If so, when?

DD slash MM slash YYYY

And which one?

Astra Zeneca

Pfizer

Other

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

Yes

Have you ever fainted after a vaccination or are you especially scared of needles?*

Yes

Have you ever had myocarditis or pericarditis?*

Yes

Do you currently have, or have you recently had acute rheumatic fever or endocarditis?*

Yes

Do you have congenital heart disease?*

Yes

For people under 30 years of age: do you have dilated cardiomyopathy?*

Yes

Do you have severe heart failure?*

Yes

Are you a recipient of a heart transplant?*

Yes

Please talk to your doctor if you have any questions or concerns before getting your COVID-19 vaccination.

Consent to receive COVID-19 vaccine

Consent*

I confirm I have received and understood information provided to me on Comirnaty (Pfizer) Covid-19 Vaccination*

Consent*

I confirm that none of the conditions above apply, or I have discussed these and/or any other special circumstances with my regular healthcare provider and/or vaccination service provider*

Consent*

I agree to receive a Comirnaty (Pfizer) Covid-19 Vaccine today*

Patient's Name

Date of Birth

DD slash MM slash YYYY

Email Address

Date

DD slash MM slash YYYY

Consent

I am the patient’s legal guardian or substitute decision maker, and agree to COVID-19 vaccination of the patient named above

Guardian/substitute

Date

DD slash MM slash YYYY

	(02) 9738-0040
	(02) 8790 6402
	info@ayamc.com.au
	17, 1 Leicester Street, Chester Hill NSW 2162

Monday	8:30 AM – 5:00 PM
Tuesday	8:30 AM – 5:00 PM
Wednesday	8:30 AM – 5:00 PM
Thursday	8:30 AM – 5:00 PM
Friday	8:30 AM – 5:00 PM
Saturday	8:30 AM – 2:00 PM
Sunday	Closed