1Registratiion Form2Consent Form Registration FormName* Surname* Email* DOB* DD slash MM slash YYYY (Date of Birth)Medicare Card No.* Reference No.* (Number Beside Your Name)Concession Card No. ( Pension Card or Healthcare Card) Address* Street Address, City, Suburb Post Code Emergency Contact Name* Emergency Contact Phone No.* Consent Form For COVID-19 VaccinationPre-Vaccination ScreeningHave you had an allergic reaction to a previous dose of a COVID-19 vaccine?* Yes No Have you had anaphylaxis to another vaccine or medication?* Yes No Have you had a serious adverse event, that following expert review was attributed to a previous dose of a COVID-19 vaccine?* Yes No Have you ever had mastocytosis (a mast cell disorder) which has caused recurrent anaphylaxis?* Yes No Have you had COVID-19 before?* Yes No Do you have a bleeding disorder?* Yes No Do you take any medicine to thin your blood (an anticoagulant therapy)?* Yes No If so, which medication do you take?* Do you have a weakened immune system (immunocompromised)?* Yes No Are you pregnant?* Yes No Have you been sick with a cough, sore throat, fever or are feeling sick in another way?* Yes No Have you had a COVID-19 vaccination elsewhere?* Yes No If so, when:* and which one?* Astra Zeneca Pfizer Moderna Have you received any other vaccination in the last 7 days?* Yes No Have you ever fainted after a vaccination or are you especially scared of needles?* Yes No Have you been diagnosed with myocarditis and/or pericarditis that is attributed to a previous dose of Pfizer or Moderna?* Yes No Have you had myocarditis, pericarditis or endocarditis within the past six months?* Yes No Do you currently have acute rheumatic fever or acute rheumatic endocarditis?* Yes No Do you have severe heart failure?* Yes No Please talk to your doctor if you have any questions or concerns before getting your COVID-19 vaccination. Consent to receive COVID-19 vaccineI confirm I have received and understood information provided to me on Comirnaty (Pfizer) Covid-19 Vaccination* I confirm I have received and understood information provided to me on Comirnaty (Pfizer) 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 healthcare provider and/or vaccination service provider* I confirm that none of the conditions above apply, or I have discussed these and/or any other special circumstances with my regular healthcare provider and/or vaccination service provider I agree to receive a Comirnaty (Pfizer) Covid-19 Vaccine today* I agree to receive a Comirnaty (Pfizer) Covid-19 Vaccine today Patient's Signature*I am the patient’s legal parent, guardian or substitute decision maker, and agree to COVID-19 vaccination of the patient named above* I am the patient’s legal parent, guardian or substitute decision maker, and agree to COVID-19 vaccination of the patient named above Parent/Guardian/Substitute Decision Maker’s Name:* Parent/Guardian/Substitute Decision Maker’s Signature:*CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ