VACCINE SCREENING AND CONSENT
Acton Health Pharmacy - COVID-19
YOUR DETAILS
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Postcode
Email
example@example.com
Phone Number
Preferably Mobile
Format: 0000000000.
Date of Birth
*
-
Day
-
Month
Year
Date
Do you have a Medicare Card?
Yes
No
Medicare Number
Remember to Include the Number next to your name as the last digit
If you have an IHI (Individual Healthcare Identifier) please provide below:
VACCINATION DETAILS
Is this your 1st, 2nd or Booster Dose?
Please Select
First
Second
Booster
What brand was your first vaccination?
Please Select
AstraZeneca (Vaxzevria)
Pfizer (CoMirnaty)
Moderna (Spikevax)
Other
If you answered "Other" - please bring evidence along to your appointment
Which Brand Would Like to Receive at the Clinic?
*
Please Select
AstraZeneca (Vaxzevria)
Moderna (Spikevax)
SCREENING
General Pre-Vaccination Screening
*
Rows
Yes
No
Have you had a serious adverse event or an allergic reaction to a previous dose of a COVID-19 vaccine?
Have you had anaphylaxis to another vaccine or medication?
Do you have a mast cell disorder which has caused recurrent anaphylaxis?
Do you have a bleeding disorder or take medication to thin your blood?
Do you have a weakened immune system or are you immunocompromised?
Are you pregnant or breastfeeding?
Have you been sick with a cough, sore throat, fever or are feeling sick in another way?
Have you received any other vaccination in the last 7 days?
Have you received immunoglobulin in the last 24 hours?
Have you received allergen immunotherapy or venom immunotherapy in the last 48 hours?
Have you been diagnosed with COVID-19 before?
Moderna (Spikevax) - Additional Information Required
*
Rows
Yes
No
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 in the past 6 months?
Do you currently have acute rheumatic fever or acute rheumatic heart disease?
Do you have severe heart failure?
AstraZeneca (Vaxzevria) - Additional Information Required
*
Rows
Yes
No
Have you ever been diagnosed with capillary leak syndrome?
Have you ever had thombosis (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 (sphlanchnic veins)?
Have you ever had antiphospholipid syndrome associated with blood clots?
Are you under 60 years of age?
ANY EXTRA INFORMATION OUR VACCINATOR SHOULD KNOW?
CONSENT
By signing this document, I, the above-named consumer, agree to have my COVID-19 vaccine administered at Acton Health Pharmacy. I have received information regarding possible side effects of the vaccine and post vaccination care - and will ask any questions I have prior to being vaccinated. I request to have this vaccination and understand that it is completely voluntary. I agree to stay in the pharmacy for 15 minutes after vaccination to monitor for reactions. For patients under 18 years of age - please ensure a parent or legal guardian signs this document.
Signature
*
For patients under 18 years - Name, Address and Relationship of legal guardian
Submit
Should be Empty: