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AVOCA STREET MEDICAL CENTRE
130 Avoca Street Randwick NSW 2031
Tel: 02 9399 3335 Fax: 02 9399 9778
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Hello and welcome to our COVID-19 vaccination clinic.
Dr Kien or Dr Angela will be giving you your COVID-19 vaccination.
In order to do this safely, we need the following information.
Please fill in all the details and submit the form to us. Thank you.
(Alternatively, you can download and complete the Vaccination Consent Form and email it to us at regos@avocastreet.com .)

PERSONAL DETAILS
Title Surname First name
Date of birth (dd/mm/yy)
Medicare card number Reference number Expiry date
Home address Postcode
Phone number Email
Next of Kin / Parent / Guardian Contact number
Are you of Aboriginal or Torres Strait Islander origin? No Yes
Language Ethnicity
List allergies and intolerances to medications

COVID-19 PRE-VACCINATION CHECKLIST
1. Have you had an allergic reaction to a previous dose of a COVID-19 vaccine?
2. Have you had anaphylaxis to another vaccine or medication?
3. Have you had a serious adverse event, that following expert review was attributed to a previous dose of a COVID-19 vaccine?
4. Have you ever had mastocytosis which has caused recurrent anaphylaxis?
5. Have you had COVID-19 before?
6. Do you have a bleeding disorder?
7. Do you take any medicine to thin your blood (an anticoagulant therapy)?
8. Do you have a weakened immune system (immunocompromised)?
9. Are you pregnant?*
10. Have you been sick with a cough, sore throat, fever or are feeling sick in another way?
11. Have you had a COVID-19 vaccination before?
12. Have you received any other vaccination in the last 7 days?
13. Have you ever been diagnosed with capillary leak syndrome? *
14. Have you ever had major venous and/or arterial thrombosis in combination with thrombocytopenia, including diagnosed Thrombotic Thrombocytopenic Syndrome (TTS), following a previous dose of a COVID-19 vaccine? *
15. Have you ever had cerebral venous sinus thrombosis? *
16. Have you ever had heparin-induced thrombocytopenia? *
17. Have you ever had blood clots in the abdominal veins (splanchnic veins)? *
18. Have you ever had antiphospholipid syndrome associated with blood clots? *
19. Are you under 60 years of age? *
20. Have you ever had myocarditis or pericarditis? **
21. Do you currently have, or have you recently had acute rheumatic fever or endocarditis? **
22. Do you have congenital heart disease? **
23. For people under 30 years of age: do you have dilated cardiomyopathy? **
24. Do you have severe heart failure? **
25. Are you a recipient of a heart transplant? **
* Comirnaty is the preferred vaccine for people in these groups but if not available, AstraZeneca COVID-19 vaccine can be considered if the benefits of vaccination outweigh the risk.
For more information refer to Patient information sheet on thrombosis with thrombocytopenia syndrome (TTS)
** There is a theoretical concern that patients with these conditions may be at increased risk of developing myocarditis and/or pericarditis after a dose of an mRNA COVID-19 vaccine, although there is no evidence to confirm this at present.
For more information refer to Guidance on Myocarditis and Pericarditis after mRNA COVID-19 Vaccines
Last updated: 30 July 2021
CONSENT
26. I confirm I have received and understood information provided to me on COVID-19 vaccination.
27. (a) I agree to receive a course of COVID-19 vaccine (two doses of the same vaccine)
(b) I am the patient's legal guardian or legal substitute decision-maker, and agree to COVID-19 vaccination of the patient named above.
Our practice uses a reminder system to help you maintain your health. The practice sends reminders by post, email, telephone or SMS for procedures such as vaccinations, Pap tests and other health reviews.
I consent to being contacted with reminders from Avoca Street Medical Centre.
Our practice also sends information to the Australian Childhood Immunisation Register and Pap Smear Register. These registers also send reminders, which can be helpful if you move.
I consent to being contacted with reminders from public health registers.
** By submitting this form I give consent for Avoca Street Medical Centre to obtain above information.

AVOCA STREET MEDICAL CENTRE

130 Avoca Street Randwick NSW 2031
Tel: 02 9399 3335 Fax: 02 9399 9778