Covid-19

Whitethorn Centre, Kilcoole, Co. Wicklow, A63 AK27

Your details

Full name (required)

Date of birth (required)

Contact number (required)

Address (required)

Gender (required)

PPSN (required)

GP name (required)

GP address (required)

Covid-19 Vaccination

Are you over 60 years of age or have an underlying medical condition?

YesNo

Are you pregnant?

YesNo

Have you had breast surgery?

YesNo

Do you feel unwell in any way?

YesNo

Have you ever had Mastocytosis (extreme allergic reaction)?

YesNo

Have you ever had an allergic reaction to any previous vaccination?

YesNo

Are you allergic to any of the vaccine residues or excipients? (Trometamol/ polyethylene glycol (PEG))

YesNo

Have you ever suffered an anaphylaxis attack?

YesNo

Have you ever had Periocarditis (inflammation of heart lining)?

YesNo

Have you ever had Myocarditis (inflammation of heart muscle)?

YesNo

Have you had COVID in the last 3 months?

YesNo

Do you have a bleeding disorder or on anticoagulants?

YesNo

Have you had any other vaccines in the last 4 weeks?

YesNo

Please list any current medical conditions, medications or allergies (optional)

I have read and understood the Covid-19 vaccination leaflet and have been given an opportunity to speak to the pharmacist providing the vaccine. I understand: the nature of the treatment; the benefits and risks of immunisation; the risks of Covid-19; the possible side effects of vaccination, when they might occur and how they should be treated. I have been given an opportunity to ask questions and raise any concerns. I agree that the details I have supplied have been recorded and those records will be kept by Mac Sherrys pharmacy.

I consent for adrenaline to be administered should it be required due to an adverse reaction post vaccination

YesNo

I agree to proceed with the vaccination for Covid-19

YesNo

I agree to have a record of vaccination stored in the pharmacy for 2 years

YesNo

Signature

Still to complete: Full name, Date of birth, Contact number, Address, Gender, PPSN, GP name, GP address, 16 questions, Signature, Security check.