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COVID-19 Consent form
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COVID-19 Consent form
You are able to download a PDF option here.
This form is to get the patient consent to receive the COVID-19 vaccine.
Title
*
Name
Surname
Age
Gender
Male
Female
Prefer Not to Answer
Address
*
Phone Number
Email
*
Do you have any serious allergies, particularly anaphylaxis, to anything, or have been prescribed an EpiPen?
Yes
No
Have you had an allergic reaction after being vaccinated before?
Yes
No
Have you had a confirmed case of Covid-19 before?
Yes
No
Do you have a bleeding disorder?
Yes
No
Do you take any medicine to thin your blood (an anticoagulant therapy)?
Yes
No
Do you have a weakened immune system (immunocompromised)?
Yes
No
Are you pregnant or think you may be or planning to be or breastfeeding?
Yes
No
Have you been sick with a cough, sore throat, fever or are feeling sick in another way?
Yes
No
Have you had a Covid-19 vaccination before?
Yes
No
Have you received any other vaccination in the last 14 days?
Yes
No
Have you had cerebral venous sinus thrombosis (a type of brain clot) in the past?
Yes
No
Have you had heparin-induced thrombocytopenia (a rare reaction to heparin treatment) in the past?
Yes
No
Consent to receive COVID-19 vaccine
Please talk to your doctor if you have any questions or concerns before getting your COVID-19 vaccination.
Please check the below to give your consent to receive the COVID-19 vaccine
I confirm I have received and understood information provided to me on Covid-19 vax;
I confirm that none of the above conditions apply, or I have discussed these or other special circumstances with my doctor or vaccination provider; and
I agree to receive a course of Covid-19 vaccine (two doses of the same vaccine).
Name
This field is for validation purposes and should be left unchanged.
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