COVID-19 Consent form for children aged 5 to 11 years Step 1 of 4 - Consent Checklist 0% 1. Has your child recently been sick with a cough, sore throat or fever, or been feeling unwell in any way?Please choose;YesNo2. Has your child had COVID-19 before?Please choose;YesNo3. Has your child had a COVID-19 vaccination before?Please choose;YesNo4. Has your child had a serious reaction to a vaccine or medication?Please choose;YesNo5. Does your child have a weakened immune system (immunocompromise) or any immune disorders?Please choose;YesNo6. Does your child have a bleeding disorder or other blood disorder, or take any medicine to thin their blood?Please choose;YesNo7. Has your child ever had any problems with their heart?Please choose;YesNo8. Are you a parent/guardian/substitute decision maker who has the authority to provide consent for vaccination on behalf of this child?Please choose;YesNoIf you answered Yes to any of questions 1 to 7, your child may still be able to receive the Pfizer COVID-19 vaccine, however you should talk to your child’s GP, Immunisation specialist or cardiologist first to discuss the best timing of vaccination and whether any additional precautions are needed. Name First Last Medicare Number: Individual Health Identifier (IHI) if applicable: Date of Birth DD slash MM slash YYYY Gender:Gender:FemaleMaleOtherLanguage spoken at home: Country of birth: Address Street Address City State ZIP / Postal Code Are you Aboriginal and/or Torres Strait Islander?Please Choose;Yes, Aboriginal onlyYes, Torres Strait Islander onlyYes Aboriginal and Torres Strait IslanderNoPrefer not to answer Parent/guardian name: Phone contact number: Email address: Consent I agree to the below termsI have received and understood information provided to me on COVID-19 vaccination for the child named above none of the above conditions apply to this child, or that I have discussed these conditions and any other special circumstances with my regular health care provider and/or vaccination provider I am the child’s parent, guardian or substitute decision-maker I have the authority to provide consent for this child and I agree to the child named above receiving the Pfizer COVID-19 vaccine.Parent/guardian/substitute decision-maker’s name: Parent/guardian/substitute decision maker’s signature:Date DD slash MM slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Filled out your form? Make a Booking online or call us on (08) 9387 2000 Book an Appointment royal australian college of practitioners AMA Your friendly GP's at Grantham House Dr Veronika Saba Dr.Med, FRACGP, DRCog, DFFP, MRCGP Dr Trina Awyong MBBS Hon, FRACGP,CLIN DIP PALL CARE Dr Anita Calalesina FRACGP, MBBS, DTMH, BSc, BA Dr Tahira Bhatti BN, MBBS, FRACGP, DRANZCOG (Adv) Dr Bronwyn Bennett MBBS FRACGP Dr Dennis Banyard MBBS Dr Robert Robinson MBBS FRACGP Dr Leon Levitt MBBS DRANZCOG Dr Maria Kailis MBBS DRANZCOG