COVID Vaccine Consent Form
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.
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