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Saint Mary Medical Centre
Saint Mary Medical Centre
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(03) 5420 7014

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COVID 19 VACCINE at SAINT MARY MEDICAL CENTRE

Our practice is administering the COVID-19 vaccination to all patients aged 12 to 100+ years old. Please call 5420 7014 to book your COVID-19 vaccination appointment.

If you are a new patient and would like to get the vaccine here, please obtain a health summary from your practice before your appointment, if possible. If you have received your previous doses somewhere else, please bring with you proof of your vaccination.

Covid vaccination consent Dose 1, 2, 3, & Booster for 12+ years old

  • 1. Covid Vaccination Information
  • 2. Patient Information
  • 3. Consent Checklist
  • 4. Declaration, Sign, Submit

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

About COVID-19 vaccination

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

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

You can have:

  • AstraZeneca or Novavax if you are 18 years or over
  • Moderna if you are 6 years or over*
  • Pfizer if you are 5 years or over*

*There are separate consent forms available for children under 12.

Pfizer, Moderna, or Novavax 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 16 years or over, including people with severe immunocompromise and pregnant women, should have a booster dose three months or more after their primary course, to prolong their protection against COVID-19.

  • People aged 16 and over can have a booster dose of Pfizer.
  • People aged 18 and over can have Pfizer or Moderna as a booster.
  • AstraZeneca is not preferred but can be used in some instances in people over 18 years.

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:

1. have had an allergic reaction, particularly a severe allergic reaction to:

  • a previous dose of a COVID-19 vaccine
  • an ingredient of a COVID-19 vaccine
  • other vaccines or medications

2. 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. 

Patient Information

Gender
Are you Aboriginal and/or Torres Strait Islander?
Next in kin (in case of emergency)

Consent Checklist

Have you had an allergic reaction to a previous dose of a COVID-19 vaccine?
Have you had anaphylaxis to another vaccine or medication?
Have you had a serious adverse event, that following expert review by an experienced immunisation provider or medical specialist was attributed to a previous dose of a COVID-19 vaccine (and did not have another cause identified)?
Have you ever had mastocytosis (a mast cell disorder) which has caused recurrent anaphylaxis?
Have you had COVID-19 before?
Do you have a bleeding disorder?
Do you take any medicine to thin your blood (an anticoagulant therapy)?
Do you have a weakened immune system (immunocompromised)?
Are you pregnant?
Pfizer and Moderna are the preferred vaccines for pregnant women. If these vaccines are not available, Novavax or AstraZeneca can be considered.
Have you been sick with a cough, sore throat, fever or are feeling sick in any way?
Have you had a COVID-19 vaccination before?
Have you received any other vaccination in the last 7 days?
Which vaccine are you receiving?

If you are receiving AstraZeneca:

Have you ever been diagnosed with capillary leak syndrome?
Have you had thrombosis (clotting) together with thrombocytopenia (low platelets) within 42 days after having a previous dose of AstraZeneca?
Have you ever had cerebral venous sinus thrombosis?
Pfizer, Moderna, or Novavax 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.
Have you ever had heparin-induced thrombocytopenia?
Pfizer, Moderna, or Novavax 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.
Have you ever had blood clots in the abdominal veins (splanchnic veins)?
Pfizer, Moderna, or Novavax 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.
Have you ever had antiphospholipid syndrome associated with blood clots?
Pfizer, Moderna, or Novavax 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.
Are you under 60 years of age?
Pfizer, Moderna, or Novavax 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

If you are receiving Pfizer or Moderna:

Have you been diagnosed with myocarditis and/or pericarditis after previous dose of Pfizer or Moderna?
Have you had myocarditis or pericarditis within the past three months?
Do you currently have acute rheumatic fever or acute rheumatic heart disease?
Do you have severe heart failure?

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.

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*See ATAGI recommendations on use of a 3rd primary dose of COVID-19 vaccine in individuals who are severely immunocompromised, ATAGI recommendations on the use of a booster dose of COVID-19 vaccine, and ATAGI recommendations on the use of Spikevax Moderna as a booster dose.

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