Covid-19 Client Detail – Appointment Booking Form

Covid-19 Client Detail –
Appointment Booking Form

To register your interest in being contacted for a Covid Vaccine appointment in your preferred Healthwise Pharmacy, please complete the details below in the covid-19 client detail box.

Please complete as many fields as possible below.

Gender (indicate):

If you are a female, please answer below:

I am pregnantI am not pregnant

Date of birth

(You will need to bring age identification with you to pharmacy at the time of your appointment.)

Indicate which vaccination cohort (if unsure please ask a member of the pharmacy team)

Residents and sta of long term care facilitiesFront line Health Care WorkersPeople with a VERY HIGH risk medical conditionPeople with a HIGH risk underlying conditionKey workers essential to the vaccination programmePeople living or working in crowded settingsAllocation group based on age

Mothers Birth Surname:

Nationality:

If you don't have a PPS Number. Please explain why:

Personal Details:

GP Details

Not Registered with a GP

1. Has this person ever had a serious allergic reaction (anaphylaxis) that needed medical treatment: *

YesNo

1a. Have they ever had a serious allergic reaction (anaphylaxis) to Trometamol (an ingredient incontrast dye used in MRI radiological studies)?
If yes, they cannot get any Comirnaty® RTU or Comirnaty® Children or any Spikevax® COVID-19vaccine. But they may be able to have a different vaccine only if 12 years or older. If no, GO TO NEXTQUESTION. *

YesNo

2. Have they ever had a serious allergic reaction (anaphylaxis):
I) after taking multiple different medications, with no reason known for the reaction. This may mean theyare allergic to polyethylene glycol (PEG) OR
II) after having a vaccine or a medicine that contains polyethylene glycol (PEG), OR
III) for unexplained reasons. This may mean they are allergic to polyethylene glycol (PEG)?
If yes, they cannot get this vaccine, they may need specialist advice. Talk to the vaccination team. If no, GO TONEXT QUESTION.*

YesNo

3. Have they ever had Mastocytosis (rare condition caused by an excess number of mast cells gathering inthe body's tissues)
If yes, they can still get the vaccine, BUT, they should be observed for 30 minutes after they are vaccinated. Go tonext question. If no, GO TO NEXT QUESTION. *

YesNo

4. Have they had Myocarditis (inflammation of the heart muscle) or Pericarditis (inflammation of the liningaround the heart) after having a previous dose of COVID-19 vaccine?
If yes, you need to answer further question 4a. If no, GO TO NEXT QUESTION 5 OR 6. *

YesNo

4a. Since they had myocarditis or pericarditis after a previous dose of COVID-19 vaccine a specialistdoctor must approve you to get this vaccine. Has your COVID-19 vaccination been approved by aspecialist doctor?
If yes, GO TO NEXT QUESTION. If no, you cannot get this vaccine. Talk to your specialist doctor to check ifyou are suitable for this or another type of COVID-19 vaccine. *

YesNo

Question 5 for 5 to 17 Years Old ony!

Has this child or young person had multisystem inflammatory syndrome also called MIS-C (a
raresyndrome usually treated in hospital) after a COVID-19 infection?
If yes, please answer question 5a and 5b. *

YesNo

5a. Has this child or young person clinically recovered from MIS-C?
If yes, GO TO QUESTION 5b.
If no, this child or young person cannot be vaccinated today. *

YesNo

5b. Has it been over 90 days since this child or young person was diagnosed with MIS-C?
If yes, GO TO NEXT QUESTION. If no, this child or young person cannot be vaccinated today. *

YesNo

6. Have they had the monkeypox or smallpox vaccine (Imvanex or Jynneos) in the last 4 weeks?
If yes, they cannot get this vaccine today. They need to wait 4 weeks after getting these vaccines before getting aCOVID-19 vaccine. If no, GO TO NEXT QUESTION. *

YesNo

7. If receiving your first or second dose of a COVID-19 vaccine, have you been diagnosed with COVID-19(with a PCR or Antigen test) within the last eight weeks?
If yes and receiving a first of a COVID-19 vaccine, you should delay getting a vaccine until you have recovered fromCOVID-19 and it has been at least 4 weeks since you tested positive or developed symptoms, or 4 weeks from yourfirst positive PCR if you did not have symptoms. If receiving a
second dose of a COVID-19 vaccine, you should delaygetting a vaccine until you have recovered from COVID-19 and it has been at least 4-8 weeks (depending on yourage) since you tested positive or developed symptoms, or 4 weeks from your first positive PCR if you did not havesymptoms. If no, GO TO NEXT QUESTION. *

YesNo

8. Does this person have a bleeding disorder or are they on anticoagulation therapy?
If yes, they can still get a vaccine if they have a bleeding disorder or take anticoagulation medicines. But tell theirvaccinator about their condition. If no, GO TO NEXT QUESTION *

YesNo

9. Are you receiving a second dose of a primary course and has it been at least 3 weeks from your first dose? If yes, an 8 week interval between dose one and dose two is now recommended for those under 30 years old. Those30 years and older or have a weak immune system (age 5 and older) a 4 week interval applies. A minimum interval of3 weeks may be used if there is urgency to achieve protection. If no, you cannot get vaccinated today. *

checkbox checkbox-16 use_label_element "Yes" "No"]

For Booster Doses Only

10. For your first round of COVID-19 vaccines (dose 1 and dose 2) did you receive Nuvaxovid for both dosesor for booster and/or additional dose?
If yes, although there is no evidence regarding the safety and efficacy of booster doses of or after Nuvaxovid, this canbe considered following an individual benefit-risk assessment. *

YesNo

11. Have you had COVID-19 infection or a COVID-19 vaccine in the last 9 months?
If yes, you should delay getting the vaccine until it has been 6 months (3 months minimal interval) from your COVID-19 infection or last COVID-19 vaccine if you are aged 50 years or older or have a weak immune system (age 5 andolder) and getting your second or subsequent booster. For healthy 12-49-year-olds receiving a second or subsequent booster you should delay getting the vaccine until ithas been 9 months (3 months minimal interval) from your COVID-19 infection or last COVID-19 vaccine.
For those receiving their first booster you should delay getting the vaccine until it has been 4 months (3 monthsminimal interval) from your COVID-19 infection or completing the primary schedule. If no, GO TO NEXT SECTION. *

YesNo

12. Are you pregnant?
If yes, complete questions 10a and 10b depending on your situation. If no, GO TO NEXT SECTION. *

YesNo

12a. If you are pregnant and have never had a COVID-19 booster before has it been 4 months since your lastCOVID-19 vaccine or infection?
If yes, you can get your your first booster vaccine. You can get your first booster at any stage of pregnancy inexceptional circumstances a minimum 3 month interval from last COVID-19 vaccine or infection can be used. Go toquestion 13b. If no, you cannot be vaccinated today. *

YesNo

12b. If you are pregnant and have had a COVID-19 booster before pregnancy are you:
- Between 20-34 weeks gestation and
- Is this your first booster in pregnancy and
- has it been 6 months since your last COVID-19 vaccine or infection?
If yes, GO TO NEXT SECTION. If no, booster doses can be given at any stage in pregnancy but ideally should begiven between 20-34 weeks. If it is more than 12 months since their previous COVID-19 vaccine or infectionadministration earlier in pregnancy should be considered. In exceptional circumstances a minimum 3 month intervalfrom last COVID-19 vaccine or infection can be used. Only women with a weak immune system can get two boostersin pregnancy. *

YesNo

For Additional Doses Only

14. If you have a weak immune system and had a COVID-19 infection more than 7 days after the secondvaccine dose, an additional dose is not required. You should get your first booster in due course. For thosewith infection within 7 days of their second dose they should complete the extended primary series after aninterval of 8 weeks (minimum interval of 4 weeks can be used). Do you meet this eligibility criteria toproceed? If yes, GO TO NEXT SECTION. If no, you cannot get vaccinated today. *

YesNo

Consent

I understand:

The nature of the treatment.
The risks of Covid-19.
The benefits and risks of immunisation.
The possible side effects of vaccination, when they might occur and how they should be treated./li>

I have been given an opportunity to ask questions and raise any concerns.

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I agree to the Healthwise Pharmacies Privacy Policy. (Please note: If you do not agree, you may fill out a vaccination registration form in store.)