Consent Form for Covid-19 Vaccination
About Covid-19 vaccination
People who have a COVID-19 vaccination have a much lower chance of getting sick from the
disease called COVID-19.

There are two brands of vaccine in use in Australia. Both are effective and safe. For adults aged
under 50 years either brand may be used, however Comirnaty (Pfizer) vaccine is preferred over
AstraZeneca COVID-19 vaccine.

You need to have two doses of the same brand of vaccine. The person giving you your
vaccination will tell you when you need to have the second vaccination.

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 around 1-2 days. As with any
vaccine or medicine, there may be rare and/or unknown side effects.

A very rare side effect of blood clotting has been reported in the 4-20 days after the first dose of
AstraZeneca COVID-19 vaccine. This is not seen after the second dose of AstraZeneca
COVID-19 vaccine or after any dose of Comirnaty (Pfizer) vaccine. For further information on
the risk of this rare condition refer to the ‘Information on COVID-19 Vaccine AstraZeneca’ fact
sheet.

You can tell your healthcare provider if you have any side effects like a sore arm, headache,
fever, or any other side effect you are worried about. You may be contacted by SMS within the
week after receiving the vaccine to see how you are feeling after vaccination.

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:

• keep your distance – stay at least 1.5 metres away from other people
• washing 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.Vaccination providers record all vaccinations on the Australian 
Immunisation Register, as required by Australian law. You can view your 
vaccination record online through your:
•	Medicare account
•	MyGov account
•	MyHealthRecord account.
How is the information you provide at your appointment used? 
For information on how your personal details are collected, stored and used visit https://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 any allergies, 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. An allergy is when you come near or in contact with something and your body reacts to it and you get sick very quickly. This may include things like an itchy rash, your tongue getting bigger, your breathing getting faster, you wheeze or your heart beating faster.
•	If you are immunocompromised. This means that you have a weakened immune system that may make it harder for you to fight infections and other diseases. Sometimes a disease like diabetes or cancer can cause this or certain medicines or treatments you take, such as medicine for cancer.
Yes	No		
		Do you have any serious allergies, particularly anaphylaxis, to anything?	
		Have you had an allergic reaction after being vaccinated before?	
		Do you have a mast cell disorder?	
		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 or do you think you might be pregnant?	
		Are you breastfeeding?	
		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 received any other vaccination in the last 14 days?	

		Have you had cerebral venous sinus thrombosis in the past?	
		Have you had heparin-induced thrombocytopenia in the past?	
		Are you under 50 years of age?	
Please talk to your doctor if you have any questions or concerns before getting your COVID-19 vaccination.

Patient Information
Name:		
Medicare number:		
Date of birth:		
Address:		
Phone contact number:		
e-mail:		
Gender:		

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	
Next of kin (in case of emergency):		
Name: 		
Phone contact number: 		

Consent to receive Covid-19 vaccine
	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)	
Patients Name 		
Patients signature + Date		

Guardian/substitute decision-maker
	I am the patient’s guardian or substitute decision-maker, and agree to 
COVID-19 vaccination of the patient named above	
Guardian/substitute decision-maker’s name:		
Guardian/substitute decision maker’s signature:		
Date:		

For provider use            Dose 1:
Date vaccine administered:		
Time received:		
COVID-19 vaccine brand administered:		
Batch no:              Serial no:		
Serial no:		
Site of vaccine injection:		
Name of vaccination service provider:		
                                  Dose 2:
Date vaccine administered:		
Time received:		
COVID-19 vaccine brand administered:		
Batch No:                 Serial no:		
Site of vaccine injection:		
Name of vaccination service provider: