Consent form for COVID-19 vaccination St Mary Medical Centre Greensborough Plaza

Before completing this form we recommend you read the Information on COVID-19 Vaccine
AstraZeneca fact sheet found on the Department of Health website (

Patient Information

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

The COVID-19 vaccination is free and you can choose whether to have the vaccination or not.

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. The more common side effects may include tenderness or pain at the injection site, headache, fever, fatigue, malaise, joint and muscle pain. 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 found on the Department of Health website.

You can tell your healthcare provider if you have any side effects like a sore arm, headache, fever, body aches or any symptom that is unusual for you. You may also be contacted after receiving the vaccine to see how you are feeling and if you have any side effects or concerns.

You will be asked to remain in the centre for 15 minutes observation after your vaccination, but if you have a previous history of anaphylaxis to a vaccine you will be required to wait for 30 minutes.

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: physical distancing, wearing a mask, enhanced personal hygiene (hand washing/sanitising), staying at home if unwell with cold-like symptoms and promptly getting tested for COVID-19.

Vaccination providers record all vaccinations on the Australian Immunisation Register, as required by Australian Law. You can view this online in your Medicare/ MyGov/MyHealthRecord account.

For information on how your personal details are collected, stored and used visit

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 (particularly polysorbate), or to any other vaccines or medications.
  • are immune-compromised. This means that you have a weakened immune system that may make it harder for you to fight infections and other diseases.
  • if you have a past history of cerebral venous sinus thrombosis (a type of brain clot) or heparin induced thrombocytopenia (a rare reaction to heparin treatment), idiopathic splanchnic (mesenteric, portal and splenic) venous thrombosis, or anti-phospholipid syndrome with thrombosis.

Pre-Vaccination Screening

    Do you have any serious allergies, particularly anaphylaxis, to anything and specifically Polysorbate 80?

    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)? If so, which medication do you take?

    Do you have a weakened immune system (immunocompromised)?

    Are you pregnant or do you think you might be pregnant?

    Have you been sick with a cough, sore throat, fever or are feeling sick in another way?

    Have you had a COVID-19 vaccination elsewhere? If so, when: _____________________ and which one?__ Astra Zeneca__ Pfizer __ Other, please specify: ____________________

    Have you received any other vaccination in the last 7 days?

    Have you ever fainted after a vaccination or are you especially scared of needles?

    Have you had cerebral venous sinus thrombosis (a type of brain clot) OR heparin induced thrombocytopenia (a rare reaction to heparin treatment) OR idiopathic splanchnic (mesenteric, portal and splenic) venous thrombosis OR anti-phospholipid syndrome with thrombosis 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.

    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 healthcare provider and/or vaccination service provider

    I agree to receive a course of COVID-19 vaccine (two doses of the same vaccine)

    I am the patient’s legal guardian or substitute decision maker, and agree to COVID-19 vaccination of the patient named above