Consent for COVID-19 vaccines
Section 1 Personal Information 13125 (2021/03/11 )
Last name First name Medicare number
Home phone Mobile phone Email Clinic location / Site information
Street address City Province Postal code
D.O.B (YYYY/MM/DD) Gender
Is this your first or second dose of the vaccine? First Second
If second, please indicate the date of the first dose:
(YYYY/MM/DD)
Male Female Other
Reason for immunization
Long term care worker Long-term care residents Group Home Shelter
Indigenous - First Nations community member: On reserve Off reserve
General Population
Health Care Worker Yes No
If yes please indicate your employer
on the right
Vitalité Health Network Horizon Health Network EM/ANB Private practice
Other (specify)
Section 2 Health information for the person being immunized (If you need more space, use the other side of this form.)
*Immunizers: please review relevant vaccine information sheet(s) with the person being immunized.
No Yes Has this person ever had a COVID-19 infection?
If yes, please indicate when the symptoms started or date of positive test results and describe any treatments received
(monoclonal antibodies or convalescent plasma)
No Yes Is this person feeling ill today or has any symptoms of COVID-19?
No Yes Does this person have any allergies, including allergies to any components of the vaccine or to medicine?
If yes, describe
No Yes Does this person have any conditions or problems with their immune system, diagnosed with an auto-immune condition or
taking medication or IV infusions which affects the immune system? (List all if more than one)
If yes, describe
No Yes Is this person taking any medicine, like anticoagulants (blood thinner) or have a bleeding disorder?
If yes, describe
No Yes Is this person pregnant? No Yes Is this person breastfeeding?
No Yes Has this person ever had a side effect from a COVID-19 vaccine or any other vaccine?
If yes, describe
No Yes
Has this person received a vaccine of any kind in the last 14 days; or plan on receiving a vaccine other than COVID-19 in the next 4 weeks?
No Yes Has this person ever felt faint or fainted after a past vaccination or medical procedure?
Section 3 Consent
For the two doses of the COVID-19 vaccine, your consent will confirm the following:
• I have read the information I was given on COVID-19 vaccine being offered to me today and consent to have administered the two required doses.
• I understand the benefits and possible reaction(s) for the COVID-19 vaccine and the risk of not being immunized.
• I have had an opportunity to discuss my questions and concerns as they relate to the COVID-19 vaccine.
• I understand that I may withdraw this consent at any time by informing the health care provider giving the COVID-19 vaccine.
• I confirm that I have the legal authority to consent to this immunization.
Printed name of
person giving
consent
Signature of
person giving
consent
Date (YYYY/MM/DD)
Relationship to person given consent: Parent (with legal authority to consent) Guardian/Legal representative
OFFICE USE ONLY
COVID-19
Lot #
Date of exp. Site Route Dosage (ml)
Date
(YYYY/MM/DD) Time
Print name and
signature of immunizer
Dose #1 - Please circle the
vaccine being given:
Moderna Pfizer-BioNTech
AstraZeneca COVISHIELD
Right arm
Left arm
IM
ml
Dose #2 - Please circle the
vaccine being given:
Moderna Pfizer-BioNTech
AstraZeneca COVISHIELD
Right arm
Left arm
IM
ml
Should you decide to provide all of the information requested on the form, it is important to know that its submission constitutes consent to the collection,
use and disclosure of your personal information.
The collection use and disclosure of personal information is protected by the Right to Information and Protection of Privacy Act (RTIPPA),
Personal Health Information Privacy and Access Act (PHIPAA) and all other applicable legislation, regulation or policy.
If you wish to know more about your privacy rights, please consult: https://www2.gnb.ca/content/dam/gnb/Departments/h-s/pdf/en/HealthActs/PrivacyNotice.pdf
