COVID Vaccination Booking

COVID Vaccination Booking Form

Please fill in details below and click 'Submit.' Your residential nurse or health & wellbeing staff member will coordinate the date and time of your appointment with you.
Name*

First NameLast Name
Name of Aged Care Residence*
Address of Aged Care Residence*
Date of Birth*

DayMonthYear
Gender*
Phone Number*
Email
example@example.com
Phone Number

Area CodePhone Number
Medicare Number*
10 digits
Medicare Reference #*
Single digit listed next to your name
Medical Conditions (Tick only those that apply)

Renal (Kidney) DiseaseHaematological DisordersImmunocompromising ConditionsDiabetes and other Metabolic DisordersCardiac DiseaseChronic Neurological ConditionsChronic Respiratory ConditionsChronic Liver DiseaseFunctional or Anatomical Asplenia
Have you ever had a severe reaction following any vaccine or medication (such as anaphylaxis)?*

YesNo
Do you have any severe allergies to anything?*

YesNo
Have you had COVID-19 before?*

YesNo
Have you ever received a COVID-19 vaccine?*

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

YesNo
Do you have a bleeding disorder or take any blood thinning medications (e.g. warfarin, heparin, anticoagulant therapy)?*

YesNo
Have you ever fainted or felt dizzy after having an injection?*

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

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

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

YesNoUnsure
Have you ever been diagnosed with capillary leak syndrome?*

YesNo
Have you been diagnosed with myocarditis and/or pericarditis after a previous dose of COVID-19 vaccine?*

YesNo
Have you had myocarditis or pericarditis in the last 3 months?*

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

YesNoUnsure
Do you have severe heart failure?*

YesNo
I certify that the information submitted in this form is true and correct to the best of my knowledge.*

Yes
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COVID Vaccination Booking Form