COVID-19 vaccination consent and pre-vaccination screening

Medical screening

Please answer every question. All answers must be reviewed by the appropriately authorised healthcare professional against the current COVID-19 vaccine-specific PGD before vaccination.

Have you ever had a severe allergic reaction, including anaphylaxis, to a previous COVID-19 vaccine, another vaccine or a vaccine component?

Yes

No

Tell us about the allergic reaction:

Do you have a known allergy to any ingredient of the COVID-19 vaccine being offered?

Yes

No

Tell us about the allergy:

Have you previously been advised by a healthcare professional not to receive a COVID-19 vaccine or a particular COVID-19 vaccine?

Yes

No

Tell us about the advice you were given:

Did you experience a serious or unexpected reaction after a previous COVID-19 vaccination that required medical assessment or treatment?

Yes

No

Tell us about the reaction:

Current health and relevant history

Have you ever been diagnosed with myocarditis or pericarditis, particularly following a previous COVID-19 vaccination or COVID-19 infection, capillary leak syndrome or Idiopathic Thrombocytopaenia (ITP)?

Yes

No

Tell us about your diagnosis:

Are you currently taking any medicines to thin your blood eg warfarin/apixaban/edoxaban or do you have a bleeding disorder?

Yes

No

Tell us about your medicine or bleeding disorder:

Have you had any lymph nodes removed/is there any reason you cannot be vaccinated in either arm?

Yes

No

Please provide more information:

If you are unwell and have a fever (temperature) on the day of your vaccination appointment, please contact reception to reschedule your appointment.

Consent

I consent to receive the COVID-19 vaccination, subject to the final eligibility and clinical assessment.

I do not consent to receive the COVID-19 vaccination.

Please select one option.

Patient declaration

I confirm that I have answered the questions above to the best of my knowledge. I understand that a trained registered healthcare professional will complete the final eligibility and clinical assessment before vaccination.

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COVID-19 vaccination consent and pre-vaccination screening

Medical screening

Current health and relevant history