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COVID Vaccine Form

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  • Home
  • About Us
    • Mission
    • Privacy
    • Fees
    • Partners
  • Our Doctors
  • Services
  • Dental
  • Allied Health
  • Afterhours Services
  • Patient Resources
  • Contact Us

COVID Vaccine Consent form

  • Consent form: AstraZeneca COVID-19 vaccination
  • Consent form: Comirnaty (Pfizer) COVID-19 vaccination

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

"*" indicates required fields

Pre-Vaccination Screening

Do you have any serious allergies, particularly anaphylaxis, to anything and specifically a COVID vaccine ingredient?*
Have you had anaphylaxis to another vaccine or medication?*
Have you had a serious adverse event, that following expert review was attributed to a previous dose of a COVID-19 vaccine?*
Have you ever had mastocytosis which has caused recurrent anaphylaxis?*
Have you had COVID-19 before?*
Do you have a bleeding disorder?*
Do you take any medicine to thin your blood (an anticoagulant therapy)? If so, which medication do you take?*
Do you have a weakened immune system (immunocompromised)?*
Are you pregnant?*
Have you been sick with a cough, sore throat, fever or are feeling sick in another way?*
Have you had a COVID-19 vaccination elsewhere?*
DD slash MM slash YYYY
And which one?

Have you received any other vaccination in the last 7 days?*
Have you ever fainted after a vaccination or are you especially scared of needles?*
Have you ever been diagnosed with capillary leak syndrome?*
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?*
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?*
Are you under 60 years of age?*

*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*
*
Consent*
*
Consent*
*
DD slash MM slash YYYY
DD slash MM slash YYYY
Consent
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

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.

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.

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 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

"*" indicates required fields

Pre-Vaccination Screening

Do you have any serious allergies, particularly anaphylaxis, to anything and specifically a COVID vaccine ingredient?*
Have you had anaphylaxis to another vaccine or medication?*
Have you had a serious adverse event, that following expert review was attributed to a previous dose of a COVID-19 vaccine?*
Have you ever had mastocytosis which has caused recurrent anaphylaxis?*
Have you had COVID-19 before?*
Do you have a bleeding disorder?*
Do you take any medicine to thin your blood (an anticoagulant therapy)? If so, which medication do you take?*
Do you have a weakened immune system (immunocompromised)?*
Are you pregnant?*
Have you been sick with a cough, sore throat, fever or are feeling sick in another way?*
Have you had a COVID-19 vaccination elsewhere?*
DD slash MM slash YYYY
And which one?

Have you received any other vaccination in the last 7 days?*
Have you ever fainted after a vaccination or are you especially scared of needles?*
Have you ever had myocarditis or pericarditis?*
Do you currently have, or have you recently had acute rheumatic fever or endocarditis?*
Do you have congenital heart disease?*
For people under 30 years of age: do you have dilated cardiomyopathy?*
Do you have severe heart failure?*
Are you a recipient of a heart transplant?*
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*
*
Consent*
*
Consent*
*
DD slash MM slash YYYY
DD slash MM slash YYYY
Consent
DD slash MM slash YYYY

AYA MC

Ingleburn Medical Centre medicare

Ingleburn Medical Centre flags We acknowledge the traditional custodians of the land on which we operate and pay our respects to elder’s past, present and emerging.

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

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Saturday 8:30 AM – 2:00 PM
Sunday Closed
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