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Vital Health Checks > Consent form for COVID-19 vaccination

Consent form for
COVID-19 vaccination

Before you fill out this form, make sure you read the information sheet on the vaccine you will be getting: Vaxzevria (AstraZeneca), Comirnaty (Pfizer) or Spikevax (Moderna).

Last updated: 24 December 2021

About COVID-19 vaccination

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

There are three brands of vaccine in use in Australia. All are effective and safe.

You can have:

  • AstraZeneca if you are 18 years or over
  • Moderna if you are 12 years or over
  • Pfizer if you are 5 years or over*

*There is a separate consent form available for children aged 5 to 11 years.

Pfizer or Moderna are preferred over AstraZeneca for adults under 60 years of age.

Most people require two doses initially. This is called the primary course.

People with severe immunocompromise may require a third primary dose to bring their immune response up to optimal levels.

People aged 18 years or over, including people with severe immunocompromise and pregnant women, can have a booster dose of Pfizer, Moderna (half dose), or AstraZeneca four months or more after their primary course, to prolong their protection against COVID-19.

For more information visit the Department of Health COVID-19 vaccine website: www.health.gov.au/covid-19-vaccines

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 one or two days. As with any vaccine or medicine, there may be rare or unknown side effects.

A very rare side effect after AstraZeneca is called thrombosis with thrombocytopenia syndrome, or TTS. This means blood clotting (thrombosis) with low blood platelet levels (thrombocytopenia). TTS does not happen after Pfizer or Moderna.

Myocarditis and pericarditis (heart inflammation) have been reported following Pfizer
and Moderna. Most cases have been mild and people have recovered quickly.

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

You may be contacted by SMS or email in the week after you have the vaccine to see how you are feeling.

Some people may get COVID-19 after vaccination. You must still follow all public health advice 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
  • wash 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.

By law, the person giving your vaccination must record it on the Australian Immunisation Register. You can view your vaccination record online through your:

  • Medicare account
  • MyGov account
  • My Health Record account (you can register for this with a Medicare number or an Individual Healthcare Identifier).

How your information is used

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

If you are getting your vaccination in a pharmacy, the pharmacy must share some of your personal information with the Pharmacy Programs Administrator. This is so the pharmacy can claim payment from the Australian Government. More information about why this is needed and what information is shared is provided at the link above.

On the day you have your vaccine

Before you get vaccinated, tell the person giving you the vaccination if you:

  • have had an allergic reaction, particularly a severe allergic reaction (anaphylaxis), to:
    • a previous dose of a COVID-19 vaccine
    • an ingredient of a COVID-19 vaccine
    • other vaccines or medications
  • are immunocompromised. This means that you have a weakened immune system that makes it harder for you to fight diseases. You can still have a COVID-19 vaccine, but talk to your doctor about when is the best time to get your vaccine. This will depend on your condition and your treatment.

    • 1

      Consent Checklist

    • 2

      Patient information

    • 3

      Consent to receive COVID-19 vaccine


    Consent Checklist

    * Pfizer or Moderna are the preferred vaccines for people in these groups. If these vaccines are not available, AstraZeneca can be considered if the benefits of vaccination outweigh the risks.

    For more information, see https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/advice-for-providers/tts

    If you are pregnant, see https://www.health.gov.au/initiatives-and-programs/covid-19-vaccines/who-can-get-vaccinated/pregnant-women

    Relevant only for those receiving Pfizer or Moderna:

    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.

    Patient information:

    Are you Aboriginal and/or Torres Strait Islander?