You need to ring the practice on 9829 3033 to get a tentative appointment time before filling this form.

Your upcoming Pfizer/Novavax vaccination

Medical experts have studied the Pfizer, Novavax vaccines to make sure they are safe. Most side effects are mild. They may start on the day of vaccination and last for around a few days. As with any vaccine or medicine, there may be rare and/or unknown side effects. The Pfzer vaccine is the preferred Covid-19 vaccine for pregnant women. It is recommended that children between 12-16 years old Comirnaty vaccine. Two injections of the vaccine is required and the recommended interval between the injections is 3 weeks.

Check list: If you have any of the conditions listed below, you may still qualify for the Pfizer or Novoavax vaccine but you must discuss your suitability for vaccination with our doctor. Please make a bulk billed appointment with us before the day of your vaccination. Please tick all that applies: *

• 1. I have not had any adverse reaction to previous Pfizer or Novavax vaccine
• 2. I do not have a haematological disease called mastocytosis
• 3. I do not have a weakened immune system (immunocompromised)
• 4. I do not have recent symptoms of being unwell - fever, cough, sore throat, etc
• 5. I have not received any other vaccinations in the last 7 days
• 6. I have not had previous myocarditis, pericarditis, endocarditis, rheumatic fever,
• 7. I do not have a congenital heart disease
• 8. I have not been diagnosed with severe heart failure
• 9. I am not a heart transplant recipient

Consent: *

• I confirm that none of the conditions above apply, or I have discussed these and/or any other special circumstances with my regular health care provider and/or vaccination service provider I agree to receive at least one dose of Pfizer Comirnaty vaccine. I will inform the doctor if I had an adverse reaction from my first Pfizer vaccination.
• I agree to remain at the practice for 15 mins after the vaccination to ensure there are no immediate adverse reactions

Name *

First

Last

Date of birth *

dd/mm/yyyy

Identify as *

• Male
• Female
• Non-binary
• Other

Address *

Suburb *

Post code *

Mobile Phone *

Email (optional)

Medicare Number *

Please ensure this is correct or your vaccination will not be recorded for your vaccination certificate

Medicare Reference No. *

Medicare Expiry Date *

mm/yy

This is my *

• First Pfizer Jab
• Second Pfizer Jab
• Booster jab (Pfizer) - 16 years and over
• kids (5-12 yo) jab
• First Novavax - 18 years and older

For patients under 18 yo, please enter name of parent providing consent:

Comment or Message

Submit

Your appointment is not confirmed till we receive your consent form above. We will email or text you the confirmed appointment time and date. If you do not receive confirmation within 24 hours, please call us on 98293033.

On the day of vaccination, please bring:

• Your Medicare Card
• A photo ID (unless <16 years old)

We expect to run on time or very close to. Please come no earlier than 10 mins before your appointment. If you are early, please stay in your car. You are expected to stay for 15 mins after your vaccination.

If you have made an appointment and you don’t turn up, the vaccine prepared for you will be wasted and discarded. Let’s not waste our precious vaccines.

Please, if you are unable to come for your appointment, you MUST ring us to cancel no less than 24 hours before your appointment time or you will not be able to book an appointment at this practice again.

All you need to know about Pfizer Comirnaty vaccine

After your Pfizer Comirnaty vaccination…