COVID CONSENT FORM

COVID CONSENT FORM

Wamberal Pharmacy

658 The Entrance Road
WAMBERAL
NSW 2260
Phone: 02 4384 1994
Email: glenkanawati@gmail.com

COVID vaccine

Pre-Immunisation
Screening and Consent

Consumer Details
Primary Healthcare Provider
Name

First NameLast Name
Address

Street Address

CityState / Province

Postal / Zip Code
Phone
Please enter a valid phone number.
Email
example@example.com
Health and Suitability for COVID-19 Vaccination
Please tell your nurse, doctor or pharmacist if you answer yes to any of the following statements as vaccination may not be suitable for you today.
Have you had an allergic reaction to a previous dose of a COVID-19 vaccine?*

YesNo
Have you had anaphylaxis to another vaccine or medication?*

YesNo
You have severe allergies (to anything)**

YesNo
Please list allergies
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)?*

YesNo
Have you ever had mastocytosis (a mast cell disorder) which has caused recurrent anaphylaxis?*

YesNo
Have you had COVID-19 before?*

YesNo
Do you have a bleeding disorder?*

YesNo
Do you take medicine to thin your blood (anticoagulant therapy)?*

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

YesNo
Are you pregnant?*

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

YesNo
Have you had a COVID-19 vaccination before?*

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

YesNo
Are you Aboriginal and/or Torres Strait Islander?*

YesNo
Have you been diagnosed with myocarditis and/or pericarditis that is attributed to a previous dose of Pfizer or Moderna?*

YesNo
Have you had myocarditis or pericarditis within the past three months?*

YesNo
Do you currently have acute rheumatic fever or acute rheumatic heart disease?*

YesNo
Do you have severe heart failure?*

YesNo
Notes
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 other vaccines or medications.

• Are immunocompromised. This means that you have a weakened immune system that may make it harder for you to fight infections and other diseases. You can still have a COVID-19 vaccine, but may wish to consider the best timing of vaccination depending on your underlying condition and/or treatment.
Consent
• I have received and understood information provided on the 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 (at least two primary doses and a booster).

• I request to have this vaccine and understand that it is completely voluntary.
Please confirm your mobile number:*
Please enter a valid phone number.
Name of patient (or parent/guardian of child): *
Signature of patient (or parent/guardian of child): Signature*
Date:
The Pre-lmmunisation Screening and Consent form ("The Document") has been developed in electronic format by MedAdVisor Intemational Pty Ltd ("MedAdvisor") based on the Practice guidelines for the provision of immunisation services within pharmacy (Dec 2014) developed by the Pharmaceutical Society of Australia (the guidelines) and the Australian Immunisation Handbook (June 2015) developed by the Australian govemment, Department of Health (the guidelines)- The Document must used in accordance with the guidelines and other relevant industry standards, codes, and laws. Consistent with the guidelines pharmacists must exercise professional judgement in using the Document, this may include adapting it to better address specific presenting circumstances. MedAdvisor accepts no liability for any loss With any person that may suffer as a result of reliance on the Document or any information contained therein.
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COVID CONSENT FORM

COVID vaccine

Pre-ImmunisationScreening and Consent

Consumer Details

Primary Healthcare Provider

Health and Suitability for COVID-19 Vaccination

Consent

Pre-Immunisation
Screening and Consent