Before completing this form make sure you have read the information sheet on the vaccine you will be receiving, either COVID-19 Vaccine AstraZeneca or Comirnaty (Pfizer). 

Last updated: 08 December 2021

About COVID-19 vaccination

People who have a COVID-19 vaccination have a much lower chance of getting sick from COVID-19.

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 (thrombosis) with low blood platelet levels (thrombocytopenia) has been reported following vaccination with the COVID-19 Vaccine AstraZeneca. This is not seen after Comirnaty (Pfizer) vaccine. For further information on the risk of this rare condition refer to the Patient information sheet on AstraZeneca COVID-19 vaccine and thrombosis with thrombocytopenia syndrome (TTS).

Tell your healthcare provider if you have any side effects after vaccination that you are worried about.

Some people may still get COVID-19 after vaccination. 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 the information you provide is used

For information on how your personal details are collected, stored and used visit https://www.health.gov.au/using-our-websites/privacy/privacy-notice-for-covid-19-vaccinations

 

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 other vaccines or medicationst
  • •  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.
*Pfizer and Moderna are the preferred vaccines for pregnant women. If these vaccines are not available, Novavax can be considered.

RELEVANT FOR PFIZER OR MODERNA COVID-19 VACCINE ONLY

If you answered Yes to any of the above questions, you may still be able to receive Pfizer or Moderna, however you should talk to your GP, immunisation specialist or cardiologist first to discuss the best timing of vaccination and whether any additional precautions are needed.
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I have received and understood the information provided to me on COVID-19 vaccination including the risks and benefits of the vaccination and the risk of not being vaccinated. I have been given the opportunity to discuss this and any other specific circumstances with my immunisation provider. I am aware of possible side effects.
I CONSENT for the above named to receive the COVID-19 vaccine ticked below. I understand that consent can be withdrawn at any time prior to vaccination.
I understand that the information I provide during the consent process, and information related to any vaccines administered, will be stored electronically and/or in hard copy as a medical record, and may be used to assist in contact tracing purposes, monitoring and reporting on the vaccine rollout and other related purposes (further information about privacy available on request).
I consent to the disclosure of this information to staff involved in the provision of an immunisation service. I acknowledge that the vaccination record will be recorded on the Australian Immunisation Register where it will be stored on my Medicare account. I understand that I may be contacted by SMS or email after receiving the vaccine to see how I am feeling after vaccination.