COVID-19 Consent form for children aged 5 to 11 years

1. Has your child recently been sick with a cough, sore throat or fever, or been feeling unwell in any way?

2. Has your child had COVID-19 before?

3. Has your child had a COVID-19 vaccination before?

4. Has your child had a serious reaction to a vaccine or medication?

5. Does your child have a weakened immune system (immunocompromise) or any immune disorders?

6. Does your child have a bleeding disorder or other blood disorder, or take any medicine to thin their blood?

7. Has your child ever had any problems with their heart?

8. Are you a parent/guardian/substitute decision maker who has the authority to provide consent for vaccination on behalf of this child?

If 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

Gender:

Language spoken at home:

Country of birth:

Address

Street Address City State ZIP / Postal Code

Are you Aboriginal and/or Torres Strait Islander?

Parent/guardian name: