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COVID-19 Consent & Medical Eligibility

You can complete this form at the pharmacy on the day of your appointment, but why not save time? Fill it out online beforehand


Birthday

Please answer the following questions with a yes or no answerPlease answer the following questions with a yes or no answer

1. Has you ever had a serious allergic reaction (anaphylaxis) that needed medical treatment? i. after having a previous dose of the Moderna (Spikevax®) or any Pfizer/BioNTech (Comirnaty®) COVID-19 Vaccines, OR ii. to any of the vaccine ingredients

If yes, you cannot get any Comirnaty® or Comirnaty® Children COVID-19 vaccine. You may need specialist advice.

If no, GO TO NEXT QUESTION.

1a. Have you ever had a serious allergic reaction (anaphylaxis) to Trometamol (an ingredient in contrast dye used in MRI radiological studies)?
2. Have you ever had a serious allergic reaction (anaphylaxis): i. after taking multiple different medications, with no reason known for the reaction. OR ii. after having a vaccine or a medicine that contains (PEG), OR iii. for unexplained reasons

If yes, you cannot get any Comirnaty® or Comirnaty® Children COVID-19 vaccine. You may need specialist advice.

If no, GO TO NEXT QUESTION.

3. Have you ever had Mastocytosis (rare condition caused by an excess number of mast cells gathering in the body’s tissues)
4. Have you had Myocarditis (inflammation of the heart muscle) or Pericarditis (inflammation of the lining around the heart) after having a previous dose of COVID-19 vaccine?

If yes, You need to answer further question 4a. If no, GO TO QUESTION 5 OR 6

4a. Since you had myocarditis or pericarditis after a previous dose of COVID-19 vaccine a specialist doctor must approve that you get this vaccine. Has your COVID-19 vaccination been approved by a specialist doctor?

Question 5 for people aged 5 to 17 years

5. Has this child or young person had multisystem inflammatory syndrome also called MIS-C (a rare syndrome usually treated in hospital) after a COVID-19 infection?
5a. Has this child or young person clinically recovered from MIS-C?

If yes, GO TO QUESTION 5b. If no, this child or young person cannot be vaccinated today.

5b. Has it been over 90 days since this child or young person was diagnosed with MIS-C?

If yes, GO TO NEXT QUESTION. If no, this child or young person cannot be vaccinated today.

6.Have you had the Mpox or smallpox vaccine (Imvanex or Jynneos) in the last 4 weeks?

If yes, you cannot get this vaccine today. You need to wait 4 weeks after getting these vaccines before

getting a COVID-19 vaccine. If no, GO TO NEXT QUESTION.

7.If receiving your first dose of a COVID-19 vaccine, have you been diagnosed with COVID-19 within the last four weeks?
8. Do you have a bleeding disorder or are you on anticoagulation therapy?

Complete this section if you are getting additional doses (a 2nd or 3rd dose) because you have a weak immune

9. If you’re receiving a second dose of a primary course because you have a weak immune system, has it been at least 3 weeks (4 weeks ideally) since your first dose of vaccine?

If yes GO TO QUESTION 9a.

If no, You should wait at least 3 weeks since their last dose.

9a. Have you been diagnosed with COVID-19 infection since your last dose of COVID-19 vaccine?

If yes, you should wait at least 4 weeks from when you tested positive or developed symptoms.

If no GO TO NEXT SECTION.

9b. If you are receiving a third dose of a primary course because you have a weak immune system, has it been at least 4 weeks since your last dose of COVID-19 vaccine?

If Yes GO TO QUESTION 9c.

If no you should wait at least 4 weeks since your last dose.

9c. If you are receiving a third dose of a primary course because you have a weak immune system, have you had COVID-19 infection since you last COVID-19 vaccine dose?

For Booster Doses only

10. Have you had COVID-19 infection or a COVID-19 vaccine in the last 3 months?
11. Are you pregnant?

Questions 11a, 11b and 11c are for pregnant persons only

11a. Have you had a booster dose already in this pregnancy?

If no GO TO QUESTION 11b

11b. Have you had COVID-19 infection or a COVID-19 vaccine in the last 6 months?

If no GO TO QUESTION 11c

11c. Have you had a COVID-19 vaccine in the last 12 months?

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For people aged 16 years and older

One of these options 1-3 is appropriate when establishing consent (please tick as appropriate)

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For people aged 15 years and younger

Please note only a parent or legal guardian can consent or refuse consent for people aged 15 years and younger.

I confirm that I am authorised to give consent on behalf of the above named young person.

I understand I am giving consent for the administration of a dose or for the primary course, consent for the administration of

one, two or three doses of COVID-19 at the appropriate interval.

Please tick
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