COVID-19 Vaccination Consent for Eligible Adults

We would like to ask if you wish to give your consent to be vaccinated. You may be offered to Pfizer/BioNTech Vaccine or the vaccine produced by Oxford/AstraZeneca.

COVID-19 vaccinations are now becoming available to adults identified as being at highest risk of catching the disease and of suffering serious complication or dying from COVID-19. The current government strategy is to offer as many high risk individuals as possible the first dose of the vaccine – with the aim being to prevent them from becoming unwell with or dying from COVID-19 disease. This vaccination is free of charge. Information about COVID-19 vaccines is available at: www.nhs.uk/coronavirus-vaccine.

COVID-19 Vaccination Consent for Eligible Adults

Please note: Vaccination is not currently taking place at the GP surgery but will be taking place at a vaccination centre in Harrow:

You will need to be able to make your way to a vaccination centre to be able to have the vaccination. Separate plans are being drawn up for those that are housebound or nursing home residents. If you indicate your consent by completing this form, you will be contacted when we are advised that there is vaccine available for your group in line with government guidance. You will be given the time and date as well as location for your vaccination. Please note two doses of the vaccine will be needed.

If you are pregnant you should not be vaccinated unless you are at high risk – you can be vaccinated after your pregnancy is over. Although the vaccine has not been tested in pregnancy, you may decide that the known risks from COVID-19 are so clear that you wish to go ahead with vaccination. There is no advice to avoid pregnancy after COVID-19 vaccination. If you are breastfeeding, you may be offered the vaccination.

Tell staff before you are vaccinated if you have ever had a serious allergic reaction (anaphylaxis). You should not have the vaccine if you've ever had a serious allergic reaction to a previous vaccine. If you do have a reaction to the vaccine, it usually happens in minutes. Staff giving the vaccine are trained to deal with allergic reactions and treat them immediately.

Like all medicines, vaccines can cause side effects. Most of these are mild and short-term, and not everyone gets them. Indications are that some vaccine recipients may experience a painful heavy arm where they had the injection and may feel tired or have a mild fever for a couple of days. These are common side effects following vaccination. If required paracetamol may help to reduce these effects and keep you as comfortable as possible following vaccination. Please read the product information for more details on the vaccine and possible side effects by searching Coronavirus Yellow Card. You can also report suspected side effects on the same website or by downloading the Yellow Card app.

During the vaccination delivery we will maintain the range of measures we have in place to keep you safe from COVID-19. Staff giving the vaccine will be wearing personal protective equipment and will abide by all our cleaning and disinfection requirements. Please expect to remain at the centre for 15 minutes after your vaccination for observation.

Please enter your details and confirm your consent below:

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Patient Details

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Any responses will be sent to this email address.

Screening

Symptoms of COVID-19 include:

  • A high temperature
  • A new, continuous cough
  • A loss or change to your sense of smell or taste
Do you currently have any COVID-19 symptoms or a confirmed COVID-19 infection in the past 4 weeks? *

These 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.

Are you able to travel to one (or more) of the vaccination centres listed above? *
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)? *
Do you take a blood thinner known as warfarin? *
Have you had a flu vaccine or any other vaccine in the last 7 days? *
Are you participating in any clinical trial for COVID-19 vaccines or have received a dose of COVID-19 vaccine in the last 21 days? *
Are you pregnant, possibly pregnant or planning to get pregnant in the next 2 months? *
Are you breastfeeding? *

Consent

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