Consent form for COVID-19 vaccination

About COVID-19 vaccination

Before you fill out this form, make sure you read the information sheet on the vaccine you will be getting: Vaxzevria (AstraZeneca), Comirnaty (Pfizer) or Spikevax (Moderna).

People who have a COVID-19 vaccination have a much lower chance of getting sick from COVID-19.

There are three brands of vaccine in use in Australia. All are effective and safe.

You can have:

    • AstraZeneca if you are 18 years or over
    • Pfizer or Moderna if you are 12 years or over.

    Pfizer or Moderna are preferred over AstraZeneca for adults under 60 years of age.

    Most people require two doses initially. This is called the primary course.

    People with severe immunocompromise may require a third primary dose to bring their immune response up to optimal levels

    People aged 18 years or over can have a booster dose of Pfizer or AstraZeneca six months or more after their primary course, to prolong their protection against COVID-19.

    See ATAGI recommendations on use of a 3rd primary dose of COVID-19 vaccine in individuals who are severely immunocompromised and ATAGI recommendations on the use of a booster dose of COVID-19 vaccine.

    Medical experts have studied COVID-19 vaccines to make sure they are safe. Most side effects are mild. They may start on the day of vaccination and last for one or two days. As with any vaccine or medicine, there may be rare or unknown side effects.

    A very rare side effect after AstraZeneca is called thrombosis with thrombocytopenia syndrome, or TTS. This means blood clotting (thrombosis) with low blood platelet levels (thrombocytopenia). TTS does not happen after Pfizer or Moderna.

    Myocarditis and pericarditis (heart inflammation) have been reported following Pfizer and Moderna. Most cases have been mild and people have recovered quickly.

    Tell your health care provider if you have any side effects after vaccination that you are worried about.

    You may be contacted by SMS or email in the week after you have the vaccine to see how you are feeling.

    Some people may get COVID-19 after vaccination. You must still follow all public health advice in your state or territory to stop the spread of COVID-19, including:

      • keep your distance – stay at least 1.5 metres away from other people
      • wash your hands often with soap and water, or use hand sanitiser
      • wear a mask
      • stay home if you are unwell with cold or flu-like symptoms and arrange to get a COVID-19 test

      By law, the person giving your vaccination must record it on the Australian Immunisation Register. You can view your vaccination record online through your:

      • Medicare account
      • MyGov account
      • My Health Record account (you can register for this with a Medicare number or an Individual Healthcare Identifier).

      How your information is used

      For information on how your personal details are collected, stored and used, visit https://www.health.gov.au/using-our-websites/privacy/privacy-notice-for-covid-19-vaccinations.

      If you are getting your vaccination in a pharmacy, the pharmacy must share some of your personal information with the Pharmacy Programs Administrator. This is so the pharmacy can claim payment from the Australian Government. More information about why this is needed and what information is shared is provided at the link above.

      On the day you have your vaccine

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

      have had an allergic reaction, particularly a severe allergic reaction (anaphylaxis), to:

      • a previous dose of a COVID-19 vaccine
      • an ingredient of a COVID-19 vaccine
      • other vaccines or medications

      are immunocompromised. This means that you have a weakened immune system that makes it harder for you to fight diseases. You can still have a COVID-19 vaccine, but talk to your doctor about when is the best time to get your vaccine. This will depend on your condition and your treatment.

      Consent Checklist

      Yes No
      Have you had an allergic reaction to a previous dose of a COVID-19 vaccine?
      Have you had anaphylaxis to another vaccine or medication?
      Have you had a serious adverse event, that following expert review by an experienced immunisation provider or medical specialist was attributed to a previous dose of a COVID-19 vaccine (and did not have another cause identified)?
      Have you ever had mastocytosis (a mast cell disorder) 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)?
      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 before?
      Have you received any other vaccination in the last 7 days?
      Relevant only for those receiving AstraZeneca:
      Have you ever been diagnosed with capillary leak syndrome?
      Have had thrombosis (clotting) together with thrombocytopenia (low platelets) within 42 days after having a previous dose of AstraZeneca?
      Have you ever had cerebral venous sinus thrombosis?
      Have you ever had heparin-induced thrombocytopenia?
      Have you ever had blood clots in the abdominal veins (splanchnic veins)?
      Have you ever had antiphospholipid syndrome associated with blood clots?
      Are you under 60 years of age?

      * Pfizer or Moderna are the preferred vaccines for people in these groups. If these vaccines are not available, AstraZeneca can be considered if the benefits of vaccination outweigh the risks.

      For more information, see to the: http://www.health.gov.au/resources/publications/patient-information-sheet-on-astrazeneca-covid-19-vaccine-and-thrombosis-with-thrombocytopenia-syndrome-tts

      If you are pregnant, see https://www.health.gov.au/resources/publications/covid-19-vaccination-shared-decision-making-guide-for-women-who-are-pregnant-breastfeeding-or-planning-pregnancy
      Relevant only for those receiving Pfizer or Moderna:
      Have you been diagnosed with myocarditis and/or pericarditis that is attributed to a previous dose of Pfizer or Moderna?
      Have you had myocarditis, pericarditis or endocarditis within the past six months?
      Do you currently have acute rheumatic fever or acute rheumatic heart disease?
      Do you have severe heart failure?
      If you answered Yes to any of the above questions, you may still be able to receive Pfizer or Moderna, however you should talk to your GP, immunisation specialist or cardiologist first to discuss the best timing of vaccination and whether any additional precautions are needed.

      Patient information

      Male Female Other

      Are you Aboriginal and/or Torres Strait Islander?

      Yes, Aboriginal only

      Yes, Torres Strait Islander only

      Yes Aboriginal and Torres Strait Islander

      No

      Prefer not to answer

      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 any other 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)

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

      Medical Centre Email id

      When you click the Finish button, an email will be sent to the medical centre with a PDF of your consent.