COVID Vaccination Consent Form

If you have been invited to get the COVID-19 vaccination, please fill out this form.

COVID-19 Vaccination Consent

COVID-19 Vaccination Consent

Section

Screening

Do you have either:

A high temperature - This means you feel hot to touch on your chest or back (you do not need to measure your temperature) *
A new, continuous cough - This means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours (if you usually have a cough, it may be worse than usual) *
Loss or change to your sense of smell or taste - This means you've noticed you cannot smell or taste anything, or things smell or taste different to normal *

Your symptoms suggest you might have Coronavirus (COVID-19). You should use the 111 online coronavirus service to find out what to do. Please do not come into the practice if you have any of these symptoms.

Have you ever had any serious reaction to a vaccination in the past where you needed to go to hospital? *
Do you suffer from any allergies or anaphylaxis reaction to medicines food or an allergic reaction that has resulted in you going to hospital? *
Do you carry an adrenaline auto-injector pen (known as Epipen, Emerade or Jext)? *
Have you had a flu vaccine or any other vaccine in the last 7 days? *
Are you pregnant, possibly pregnant or planning to get pregnant in the next 2 months? *
Are you breastfeeding? *

Consent

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