HNZ00034113 Appendix p13
COVID-19 vaccination
consent form
Patient
Surname
First name
Phone
Date of birth
NHI
Address
Medical Centre/GP
Parent / guardian / enduring power of attorney
the 1982
Name of parent or guardian (if applicable)
Relationship to patient
Please let the vaccinator know:
Act
• If you are unwell
• If you are aged under 12 years
under
• If you are pregnant
• If you’re on blood-thinning medications or have a bleeding disorder
• If you’ve had a previous severe allergic reaction to any vaccine or injection in the past
• If you have had myocarditis or pericarditis after a vaccination in the past
I have read the COVID-19 information provided, and/or have had explained to me information about
the COVID-19 vaccine.
I have had a chance to ask questions and they were answered to my satisfaction.
I believe I understand the benefits and risks of COVID-19 vaccination.
Information
I understand it is my choice to get the COVID-19 vaccination.
Released
I understand I will need 2 doses of the Pfizer COVID-19 vaccine to have the best protection.
Signature
Date
I am the parent, guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
patient named above.
Official
Signature
Date
HP7565 | 9 September 2021
HNZ00034113 Appendix p14
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date Time
If deferred, declined or not medical fit for vaccine record detail
the 1982
Vaccine
Diluent
Act
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
reconstitution
Pfizer/BioNTech
0.3ml
under
COVID-19
Vaccine
Dose 1
Dose 2
Post vaccination information given
Signature of vaccinator
Name of vaccinator
Released
Information
Observation area information
Signature
Details of any AEFI or observations recorded
Departure time
CARM Report completed
Official
HNZ00034113 Appendix p15
COVID-19 vaccination
consent form
Patient
Surname
First name
Phone
Date of birth
NHI
Address
Medical Centre/GP
Please let the vaccinator know:
• If you are unwell
• If you are aged under 12 years
the 1982
• If you are pregnant
• If you’re on blood-thinning medications or have a bleeding disorder
• If you’ve had a previous severe allergic reaction to any vaccine or injection in the past
• If you have had myocarditis or pericarditis after a vaccination in the past
Act
I have read the COVID-19 information provided, and/or have had explained to me information
about the COVID-19 vaccine.
under
I have had a chance to ask questions and they were answered to my satisfaction.
I believe I understand the benefits and risks of COVID-19 vaccination.
I understand it is my choice to get the COVID-19 vaccination.
I understand I will need 2 doses of the Pfizer COVID-19 vaccine to have the best protection.
Signature
Date
Parent / guardian / enduring power of attorney
I am the parent, guardian or enduring power of attorney, and agree to the COVID-19 vaccination
of the patient named above.
Name of parent or guardian
Relationship to patient
Signature
Date
Released
Information
Third primary dose
I understand I am receiving a third primary dose to provide increased protection against COVID-19.
Signature
Date
Medical practitioner
I confirm I have explained the reasons for, the risks and outcomes of a third primary vaccination
to the consumer named above.
Official
Signature
Date
P L E A S E N O T E : A prescription from a medical practitioner is required for a third primary dose.
HP7565 | COVID-19 vaccine consent form general | 22 Oct 2021
HP7565 Covid-19 Vaccine consent form general V22.indd 1
22/10/21 4:21 PM
HNZ00034113 Appendix p16
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date Time
If deferred, declined or not medical fit for vaccine record detail
the 1982
Vaccine
Diluent
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
Act reconstitution
Pfizer/BioNTech
0.3ml
COVID-19
under
Vaccine
Dose 1
Dose 2
Dose 3
Post vaccination information given
Signature of vaccinator
Name of vaccinator
Observation area information
Signature
Details of any AEFI or observations recorded
Information
Departure time
Released
CARM Report completed
Vaccination site clinical lead
If administering a third primary dose, this should be signed below by the clinical lead.
Name
Signature
Date
Official
In the case of a third primary dose, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HP7565 Covid-19 Vaccine consent form general V22.indd 2
22/10/21 4:21 PM
HNZ00034113 Appendix p17
COVID-19 vaccination
consent form
Patient
Surname
First name
Phone
Date of birth
NHI
Address
Medical Centre/GP
Please let the vaccinator know:
If you are receiving Pfizer,
If you are receiving AstraZeneca,
please let your vaccinator know:
please let your vaccinator know:
• If you are unwell
• If you are pregnant
• If you are aged under 12 years
• If you are aged under 18 years
• If you’re on blood-thinning
• If you have had myocarditis or
• If you’ve ever had a major clot or low
medications or have a bleeding
pericarditis after a vaccination
blood platelets in the past, or have an
disorder
in the past
autoimmune condition that means
the
you are more likely to have a clot
1982
• If you’ve had a previous severe
allergic reaction to any vaccine
• If you’ve ever had capillary leak
or injection in the past
syndrome, a rare condition causing
fluid leakage from small blood vessels
Act
I have read the COVID-19 information provided, and/or have had explained to me
information about the COVID-19 vaccine.
I have been informed of the contraindications of the COVID-19 vaccine.
under
I have had a chance to ask questions and they were answered to my satisfaction.
I believe I understand the benefits and risks of COVID-19 vaccination.
I understand it is my choice to get the COVID-19 vaccination.
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
Signature
Date
Parent / guardian / enduring power of attorney
I am the parent, guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
patient named above.
Released
Information
Name of parent or guardian
Relationship to patient
Signature
Date
Tick the vaccine dose that applies:
Official
Pfizer
AstraZeneca
Dose 1
Dose 2
Dose 1
Dose 2**
Dose 3*
Dose 3*
Booster
Booster*
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
Signature
Date
* These doses are considered off-label use.
** AstraZeneca as a second primary dose following a non-AstraZeneca dose is considered off-label use.
HP7565 | 24 November 2021
HNZ00034113 Appendix p18
Medical practitioner
I confirm that I have explained the reasons for, the risks and outcomes of the
Pfizer or
AstraZeneca
vaccination to the patient named on this consent form.
(please circle one)
Signature
Date
PLEASE NOTE: A prescription from a medical practitioner is required for a third primary dose of Pfizer. A prescription is
recommended for AstraZeneca as a booster dose or a second primary (ie. following a non-AstraZeneca vaccine for dose 1).
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
If deferred, declined or not medically fit for vaccine, record detail:
the 1982
Vaccine
Diluent
Pfizer only
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
reconstitution
Act
Pfizer/BioNTech
0.3mL
COVID-19 Vaccine
AstraZeneca
0.5mL
under
Pfizer
AstraZeneca
Dose 1
Dose 2
Dose 1
Dose 2**
Dose 3*
Dose 3*
Booster
Booster*
* These doses are considered off-label use.
** AstraZeneca as a second primary dose following a non-AstraZeneca dose is considered off-label use.
Vaccinator information
Observation area information
Name
Details of any AEFI or observations recorded
Signature
CARM Report completed
Released
Information
Post vaccination information given
Signature
Departure time
Vaccination site clinical lead
If administering an off-label use, such as a third primary dose, AstraZeneca vaccine as a booster dose OR
AstraZeneca as the secondary dose of the primary course (ie following non-AstraZeneca COVID-19 vaccine for
dose 1), this should be signed below by the clinical lead.
Official
Name
Signature
Date
When a prescription is used, the prescriber must retain this form or a copy, and hold securely as a medical record
in accordance with local policy.
HNZ00034113 Appendix p37
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
Address
Medical Centre/GP
NHI
Please let the vaccinator know: If you are receiving Pfizer,
If you are receiving AstraZeneca,
please let your vaccinator know: please let your vaccinator know:
• If you are unwell
• If you are pregnant
• If you are aged under 12 years
• If you are aged under 18 years
you will get the paediatric dose
• If you’re on blood-thinning
• If you are pregnant
medications or have a
• If you have had myocarditis or
• If you’ve ever had a major clot or low blood platelets
bleeding disorder
pericarditis after a vaccination
in the past, or have an autoimmune condition that
in the past
• If you’ve had a previous severe
means you are more likely to have a clot
the 1982
allergic reaction to any vaccine
• If you’ve ever had capillary leak syndrome, a
or injection in the past
rare condition causing fluid leakage from small
blood vessels
I have read the COVID-19 information provided, and/or have had explained to
Act
me information about the COVID-19 vaccine.
I have had a chance to ask questions and they were answered to my satisfaction.
under
I believe I understand the benefits and risks of COVID-19 vaccination.
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
person named above.
Released
Information
Name of parent or legal guardian
Relationship to person being vaccinated
Signature
Date
Tick the vaccine dose that applies:
Dose 1
Dose 2
Paediatric Pfizer
Official
5-12 years
5-12 years
Dose 1
Dose 2
Dose 3*
Booster
Pfizer
12 years and above
12 years and above
12 years and above
18 years and above
Dose 1
Dose 2**
Dose 3*
Booster*
AstraZeneca
18 years and above
18 years and above
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
Signature
Date
* These doses are considered off-label use.
** AstraZeneca as a second primary dose following a non-AstraZeneca dose is considered off-label use.
HP7565 | 17 December 2021
HNZ00034113 Appendix p38
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacy prescriber)
I confirm that I have explained the reasons for, the risks and outcomes of the
Pfizer or
AstraZeneca
vaccination to the person named on this consent form.
(please circle one)
Signature
Date
PLEASE NOTE: A prescription from an authorised prescriber is required for a third primary dose of Pfizer. A prescription is
recommended for AstraZeneca as a booster dose or a second primary (ie. following a non-AstraZeneca vaccine for dose 1).
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
Vaccine
Diluent
Pfizer only
the 1982
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
reconstitution
Paediatric Pfizer
0.2mL
Pfizer/BioNTech
0.3mL
Act
AstraZeneca
0.5mL
Dose 1
Dose 2
under
Paediatric Pfizer
5-12 years
5-12 years
Dose 1
Dose 2
Dose 3*
Booster
Pfizer
12 years and above
12 years and above
12 years and above
18 years and above
Dose 1
Dose 2**
Dose 3*
Booster*
AstraZeneca
18 years and above
18 years and above
18 years and above
18 years and above
* These doses are considered off-label use.
** AstraZeneca as a second primary dose following a non-AstraZeneca dose is considered off-label use.
Vaccinator information
Observation area information
Name
Details of any AEFI or observations recorded
Signature
CARM Report completed
Released
Information
Post vaccination information given
Signature
Departure time
Vaccination site clinical lead
If administering an off-label use, such as a third primary dose, AstraZeneca vaccine as a booster dose OR
AstraZeneca as the secondary dose of the primary course (ie following non-AstraZeneca COVID-19 vaccine for
Official
dose 1), this should be signed below by the clinical lead.
Name
Signature
Date
When a prescription is used, the prescriber must retain this form or a copy, and hold securely as a medical record
in accordance with local policy.
HNZ00034113 Appendix p19
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer,
If you are receiving AstraZeneca,
please let your vaccinator know:
please let your vaccinator know:
• If you are unwell
• If you are aged under 12 years
• If you are aged under 18 years
• If you are pregnant or
you will get the paediatric dose
breastfeeding
• If you’ve ever had a major clot or low
• If you have had myocarditis or
blood platelets in the past, or have an
• If you’re on blood-thinning
pericarditis after a vaccination
autoimmune condition that means you
medications or have a
in the past
are more likely to have a clot
bleeding disorder
If you are receiving Novavax,
• If you’ve ever had capillary leak
• If you’ve had a previous severe
the 1982
please let your vaccinator know:
syndrome, a rare condition causing
allergic reaction to any vaccine
or injection in the past
• If you are aged under 18 years
fluid leakage from small blood vessels
I have read the COVID-19 information provided, and/or have had explained to
me information about the COVID-19 vaccine.
Act
I have had a chance to ask questions and they were answered to my satisfaction.
I understand the benefits and risks of COVID-19 vaccination.
under
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
person named above.
Name of parent or legal guardian
Phone
Released
Information
Relationship to person being vaccinated
Signature
Date
Tick the vaccine dose that applies:
Dose 1
Dose 2
Paediatric Pfizer
5-12 years
5-12 years
Dose 1
Dose 2
Dose 3*
Booster
Pfizer
12 years and above
12 years and above
12 years and above
18 years and above
Official
Dose 1
Dose 2**
Dose 3*
Booster*
AstraZeneca
18 years and above
18 years and above
18 years and above
18 years and above
Dose 1
Dose 2**
Novavax
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule)
is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 9 March 2022
HNZ00034113 Appendix p20
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacy prescriber)
I confirm that I have explained the reasons for, the risks and outcomes of the
Pfizer,
AstraZeneca or
Novavax vaccination to the person named on this consent form.
(please circle one above)
Name
APC number
Signature
Date
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
Vaccine
Diluent
Pfizer only
the
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
1982
reconstitution
Paediatric Pfizer
0.2mL
Pfizer/BioNTech
0.3mL
Act
AstraZeneca
0.5mL
Novavax
0.5mL
under
Dose 1
Dose 2
Paediatric Pfizer
5-12 years
5-12 years
Dose 1
Dose 2
Dose 3*
Booster
Pfizer
12 years and above
12 years and above
12 years and above
18 years and above
Dose 1
Dose 2**
Dose 3*
Booster*
AstraZeneca
18 years and above
18 years and above
18 years and above
18 years and above
Dose 1
Dose 2**
Novavax
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Information
Vaccinator information
Observation area information
Released
Name
Details of any AEFI or observations recorded
CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
Official
If administering an off-label use, this should be signed below by the clinical lead.
Name
Signature
Date
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p21
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer,
If you are receiving AstraZeneca,
please let your vaccinator know:
please let your vaccinator know:
• If you are unwell
• If you are aged under 12 years
• If you are aged under 18 years
• If you are pregnant or
you will get the paediatric dose
breastfeeding
• If you’ve ever had a major clot or low
• If you have had myocarditis or
blood platelets in the past, or have an
• If you’re on blood-thinning
pericarditis after a vaccination
autoimmune condition that means you
medications or have a
in the past
are more likely to have a clot
bleeding disorder
If you are receiving Novavax,
• If you’ve ever had capillary leak
• If you’ve had a previous severe
the
please let your vaccinator know:
1982
syndrome, a rare condition causing
allergic reaction to any vaccine
or injection in the past
• If you are aged under 18 years
fluid leakage from small blood vessels
I have read the COVID-19 information provided, and/or have had explained to
me information about the COVID-19 vaccine.
Act
I have had a chance to ask questions and they were answered to my satisfaction.
I understand the benefits and risks of COVID-19 vaccination.
under
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date DD MM YYYY
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
person named above.
Name of parent or legal guardian
Phone
Released
Information
Relationship to person being vaccinated
Signature
Date DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer
Dose 1
Dose 1
Dose 3*
5-11 years
5-11 years
5-11 years
Pfizer
Dose 1
Dose 2
Dose 3*
Booster
12 years and above
12 years and above
12 years and above
16 years and above
Official
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Novavax
Dose 1
Dose 2**
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date DD MM YYYY
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 19 May 2022
HNZ00034113 Appendix p22
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacy prescriber)
I confirm that I have explained the reasons for, the risks and outcomes of the
Pfizer,
AstraZeneca or
Novavax vaccination to the person named on this consent form.
(please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
DD MM YYYY
Vaccine
Diluent
Pfizer only
the
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
1982
reconstitution
Paediatric Pfizer
0.2mL
Pfizer/BioNTech
0.3mL
Act
AstraZeneca
0.5mL
Novavax
0.5mL
under
Paediatric Pfizer
Dose 1
Dose 1
Dose 3*
5-11 years
5-11 years
5-11 years
Pfizer
Dose 1
Dose 2
Dose 3*
Booster
12 years and above
12 years and above
12 years and above
16 years and above
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Novavax
Dose 1
Dose 2**
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Released
Information
Details of any AEFI or observations recorded
Name
CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
Official
the consumer.
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p23
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer,
If you are receiving AstraZeneca,
please let your vaccinator know:
please let your vaccinator know:
• If you are unwell
• If you are aged under 12 years
• If you are aged under 18 years
• If you are pregnant or
you will get the paediatric dose
breastfeeding
• If you’ve ever had a major clot or low
• If you have had myocarditis or
blood platelets in the past, or have an
• If you’re on blood-thinning
pericarditis after a vaccination
autoimmune condition that means you
medications or have a
in the past
are more likely to have a clot
bleeding disorder
If you are receiving Novavax,
• If you’ve ever had capillary leak
• If you’ve had a previous severe
the
please let your vaccinator know:
1982
syndrome, a rare condition causing
allergic reaction to any vaccine
or injection in the past
• If you are aged under 18 years
fluid leakage from small blood vessels
I have read the COVID-19 information provided, and/or have had explained to
me information about the COVID-19 vaccine.
Act
I have had a chance to ask questions and they were answered to my satisfaction.
I understand the benefits and risks of COVID-19 vaccination.
under
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date DD MM YYYY
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
person named above.
Name of parent or legal guardian
Phone
Released
Information
Relationship to person being vaccinated
Signature
Date DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2*
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
Official
16 years and above
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Novavax
Dose 1
Dose 2**
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date DD MM YYYY
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 25 May 2022
HNZ00034113 Appendix p24
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacy prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer,
AstraZeneca or
Novavax vaccination to the person named on this consent form.
(please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
DD MM YYYY
Vaccine
Diluent
Pfizer only
the
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
1982
reconstitution
Paediatric Pfizer
0.2mL
Pfizer/BioNTech
0.3mL
Act
AstraZeneca
0.5mL
Novavax
0.5mL
under
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2*
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Novavax
Dose 1
Dose 2**
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Released
Information
Details of any AEFI or observations recorded
Name
CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
Official
the consumer.
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p25
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer,
If you are receiving AstraZeneca,
please let your vaccinator know:
please let your vaccinator know:
• If you are unwell
• If you are aged under 12 years
• If you are aged under 18 years
• If you are pregnant or
you will get the paediatric dose
breastfeeding
• If you’ve ever had a major clot or low
• If you have had myocarditis or
blood platelets in the past, or have an
• If you’re on blood-thinning
pericarditis after a vaccination
autoimmune condition that means you
medications or have a
in the past
are more likely to have a clot
bleeding disorder
If you are receiving Novavax,
• If you’ve ever had capillary leak
• If you’ve had a previous severe
the
please let your vaccinator know:
1982
syndrome, a rare condition causing
allergic reaction to any vaccine
or injection in the past
• If you are aged under 18 years
fluid leakage from small blood vessels
I have read the COVID-19 information provided, and/or have had explained to
me information about the COVID-19 vaccine.
Act
I have had a chance to ask questions and they were answered to my satisfaction.
I understand the benefits and risks of COVID-19 vaccination.
under
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date DD MM YYYY
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
person named above.
Name of parent or legal guardian
Phone
Released
Information
Relationship to person being vaccinated
Signature
Date DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2*
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
Official
16 years and above
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Novavax
Dose 1
Dose 2**
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date DD MM YYYY
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 27 June 2022
HNZ00034113 Appendix p26
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacy prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer,
AstraZeneca or
Novavax vaccination to the person named on this consent form.
(please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
DD MM YYYY
Vaccine
Diluent
Pfizer only
the
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
1982
reconstitution
Paediatric Pfizer
0.2mL
Pfizer/BioNTech
0.3mL
Act
AstraZeneca
0.5mL
Novavax
0.5mL
under
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2*
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Novavax
Dose 1
Dose 2**
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Released
Information
Details of any AEFI or observations recorded
Name
CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
Official
the consumer.
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p27
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer,
If you are receiving AstraZeneca,
please let your vaccinator know:
please let your vaccinator know:
• If you are unwell
• If you are aged under 12 years
• If you are aged under 18 years
• If you are pregnant or
you will get the paediatric dose
breastfeeding
• If you’ve ever had a major clot or low
• If you have had myocarditis or
blood platelets in the past, or have an
• If you’re on blood-thinning
pericarditis after a vaccination
autoimmune condition that means you
medications or have a
in the past
are more likely to have a clot
bleeding disorder
If you are receiving Novavax,
• If you’ve ever had capillary leak
• If you’ve had a previous severe
the
please let your vaccinator know:
1982
syndrome, a rare condition causing
allergic reaction to any vaccine
or injection in the past
• If you are aged under 18 years
fluid leakage from small blood vessels
I have read the COVID-19 information provided, and/or have had explained to
me information about the COVID-19 vaccine.
Act
I have had a chance to ask questions and they were answered to my satisfaction.
I understand the benefits and risks of COVID-19 vaccination.
under
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date DD MM YYYY
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
person named above.
Name of parent or legal guardian
Phone
Released
Information
Relationship to person being vaccinated
Signature
Date DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2*
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
Official
16 years and above
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Novavax
Dose 1
Dose 2**
Booster
18 years and above
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date DD MM YYYY
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 4 July 2022
HNZ00034113 Appendix p28
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacy prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer,
AstraZeneca or
Novavax vaccination to the person named on this consent form.
(please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
DD MM YYYY
Vaccine
Diluent
Pfizer only
the
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
1982
reconstitution
Paediatric Pfizer
0.2mL
Pfizer/BioNTech
0.3mL
Act
AstraZeneca
0.5mL
Novavax
0.5mL
under
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2*
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Novavax
Dose 1
Dose 2**
Booster
18 years and above
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Released
Information
Details of any AEFI or observations recorded
Name
CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
Official
the consumer.
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p29
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer,
If you are receiving AstraZeneca,
please let your vaccinator know:
please let your vaccinator know:
• If you are unwell
• If you are aged under 12 years
• If you are aged under 18 years
• If you are pregnant or
you will get the paediatric dose
breastfeeding
• If you’ve ever had a major clot or low
• If you have had myocarditis or
blood platelets in the past, or have an
• If you’re on blood-thinning
pericarditis after a vaccination
autoimmune condition that means you
medications or have a
in the past
are more likely to have a clot
bleeding disorder
If you are receiving Novavax,
• If you’ve ever had capillary leak
• If you’ve had a previous severe
the
please let your vaccinator know:
1982
syndrome, a rare condition causing
allergic reaction to any vaccine
or injection in the past
• If you are aged under 18 years
fluid leakage from small blood vessels
I have read the COVID-19 information provided, and/or have had explained to
me information about the COVID-19 vaccine.
Act
I have had a chance to ask questions and they were answered to my satisfaction.
I understand the benefits and risks of COVID-19 vaccination.
under
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date DD MM YYYY
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
person named above.
Name of parent or legal guardian
Phone
Released
Information
Relationship to person being vaccinated
Signature
Date DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
Official
16 years and above
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
18 years and above
18 years and above
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date DD MM YYYY
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 13 July 2022
HNZ00034113 Appendix p30
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacy prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer,
AstraZeneca or
Novavax vaccination to the person named on this consent form.
(please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
DD MM YYYY
Vaccine
Diluent
Pfizer only
the
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
1982
reconstitution
Paediatric Pfizer
0.2mL
Pfizer/BioNTech
0.3mL
Act
AstraZeneca
0.5mL
Novavax
0.5mL
under
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
AstraZeneca
Dose 1
Dose 2**
Dose 3*
Booster*
18 years and above
18 years and above
18 years and above
18 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
18 years and above
18 years and above
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Released
Information
Details of any AEFI or observations recorded
Name
CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
Official
the consumer.
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p31
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
If you are receiving Pfizer, please let your
Please let the vaccinator know:
vaccinator know:
• If you are unwell
• If you are aged under 12 years you will get the
• If you are pregnant or breastfeeding
paediatric dose
• If you’re on blood-thinning medications or
• If you have had myocarditis or pericarditis
have a bleeding disorder
after a vaccination in the past
the
If you are receiving Novavax, please let your
• If you’ve had a previous severe allergic reaction
1982
vaccinator know:
to any vaccine or injection in the past
• If you are aged under 18 years
I have read the COVID-19 information provided, and/or have had explained to
Act
me information about the COVID-19 vaccine.
I have had a chance to ask questions and they were answered to my satisfaction.
under
I understand the benefits and risks of COVID-19 vaccination.
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date DD MM YYYY
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
person named above.
Name of parent or legal guardian
Phone
Released
Information
Relationship to person being vaccinated
Signature
Date DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Official
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
18 years and above
18 years and above
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date DD MM YYYY
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 5 September 2022
HNZ00034113 Appendix p32
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacy prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer or
Novavax vaccination
to the person named on this consent form. (please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
DD MM YYYY the
Vaccine
Diluent
1982
Pfizer only
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
reconstitution
Paediatric Pfizer
0.2mL
Act
Pfizer/BioNTech
0.3mL
Novavax
0.5mL
under
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
18 years and above
18 years and above
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Details of any AEFI or observations recorded
Information
Name
Released CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
the consumer.
Official
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p33
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer, please let your
• If you have had myocarditis or pericarditis
vaccinator know:
in the past
• If you are aged under 12 years you will get the
• If you are unwell
paediatric dose
• If you’re on blood-thinning medications or
If you are receiving Novavax, please let your
have a bleeding disorder
vaccinator know: the 1982
• If you’ve had a previous severe allergic reaction
• If you are aged under 18 years
to any vaccine or injection in the past
I have read the COVID-19 information provided, and/or have had explained to
Act
me information about the COVID-19 vaccine.
I have had a chance to ask questions and they were answered to my satisfaction.
under
I understand the benefits and risks of COVID-19 vaccination.
I understand I will need 2 doses of the COVID-19 vaccine to be fully vaccinated.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date DD MM YYYY
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination of the
person named above.
Name of parent or legal guardian
Phone
Released
Information
Relationship to person being vaccinated
Signature
Date DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Official
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
18 years and above
18 years and above
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date DD MM YYYY
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 8 September 2022
HNZ00034113 Appendix p34
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacy prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer or
Novavax vaccination
to the person named on this consent form. (please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
Record information and advice given:
Informed consent obtained? Yes No
Date
Time
DD MM YYYY the
Vaccine
Diluent
1982
Pfizer only
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
reconstitution
Paediatric Pfizer
0.2mL
Act
Pfizer/BioNTech
0.3mL
Novavax
0.5mL
under
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
18 years and above
18 years and above
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Details of any AEFI or observations recorded
Information
Name
Released CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
the consumer.
Official
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p35
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer, please let your
• If you have had myocarditis or pericarditis
vaccinator know:
in the past
• If you are aged under 12 years you will get the
• If you are unwell
paediatric dose
• If you’re on blood-thinning medications or
If you are receiving Novavax, please let your
have a bleeding disorder
vaccinator know: the 1982
• If you’ve had a previous severe allergic reaction
• If you are aged under 18 years
to any vaccine or injection in the past
I have read the COVID-19 information provided, and/or have had explained to
Act
me information about the COVID-19 vaccine.
I have had a chance to ask questions and they were answered to my satisfaction.
under
I understand the benefits and risks of COVID-19 vaccination.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Parent / legal guardian / enduring power of attorney
Date
/
/
DD MM YYYY
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination
of the person named above.
Name of parent or legal guardian
Released
Information
Relationship to person being vaccinated
Phone
Signature
Date
/ /
DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
Official
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
18 years and above
18 years and above
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date DD MM YYYY
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 30.09.22
HNZ00034113 Appendix p36
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacist prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer or
Novavax vaccination
to the person named on this consent form. (please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
If yes, record information and advice given:
Informed consent obtained? Yes No
Date
/
/
Time
DD MM YYYY the 1982
Vaccine
Diluent
Pfizer only
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
reconstitution
Paediatric Pfizer
0.2mL
Act
Pfizer/BioNTech
0.3mL
under
Novavax
0.5mL
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
18 years and above
18 years and above
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Details of any AEFI or observations recorded
Information
Name
Released CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
the consumer.
Official
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p43
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer,
• If you have had myocarditis or pericarditis
please let your vaccinator know:
after a vaccination in the past
• If you are aged under 12 years you wil
• If you are pregnant or breastfeeding
get the paediatric dose
the
• If you have diabetes
If you are receiving Novavax,
1982
• If you are unwell
please let your vaccinator know:
• If you’re on blood-thinning medications
• If your first dose was Pfizer
or have a bleeding disorder
• If you’ve had a previous severe al ergic reaction
Act
to any vaccine or injection in the past
I have read the COVID-19 information provided, and/or have had explained to
under
me information about the COVID-19 vaccine.
I have had a chance to ask questions and they were answered to my satisfaction.
I understand the benefits and risks of COVID-19 vaccination.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date
/
/
DD MM YYYY
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination
of the person named above.
Released
Information
Name of parent or legal guardian
Relationship to person being vaccinated
Phone
Signature
Date
/
/
DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Official
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
12 years and above
12 years and above
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
DD MM YYYY
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 05.10.22
HNZ00034113 Appendix p44
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacist prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer or
Novavax vaccination
to the person named on this consent form. (please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
If yes, record information and advice given:
Informed consent obtained? Yes No
Date
/
/
Time
DD MM YYYY the 1982
Vaccine
Diluent
Pfizer only
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
reconstitution
Paediatric Pfizer
0.2mL
Act
Pfizer/BioNTech
0.3mL
under
Novavax
0.5mL
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
12 years and above
12 years and above
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Details of any AEFI or observations recorded
Information
Name
Released CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
the consumer.
Official
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p45
COVID-19 vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
Please let the vaccinator know:
If you are receiving Pfizer,
• If you have had myocarditis or pericarditis
please let your vaccinator know:
after a vaccination in the past
• If you are aged under 12 years
• If you are pregnant or breastfeeding
(you will get the paediatric dose)
the
• If you have diabetes
If you are receiving Novavax,
1982
• If you are unwell
please let your vaccinator know:
• If you’re on blood-thinning medications
• If your first dose was not Novavax
or have a bleeding disorder
• If you’ve had a previous severe al ergic reaction
Act
to any vaccine or injection in the past
I have read the COVID-19 information provided, and/or have had explained to
under
me information about the COVID-19 vaccine.
I have had a chance to ask questions and they were answered to my satisfaction.
I understand the benefits and risks of COVID-19 vaccination.
I have been told how to seek assistance if I experience symptoms that may be vaccine side effects.
I understand the side effects associated with this vaccine and know how to get help if needed.
Signature
Date
/
/
DD MM YYYY
Parent / legal guardian / enduring power of attorney
I am the parent, legal guardian or enduring power of attorney, and agree to the COVID-19 vaccination
of the person named above.
Released
Information
Name of parent or legal guardian
Relationship to person being vaccinated
Phone
Signature
Date
/
/
DD MM YYYY
Tick the vaccine dose that applies:
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Official
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
12 years and above
12 years and above
18 years and above
18 years and above
I understand that I am receiving a vaccine as indicated above and understand the information given to me.
I agree to receive the vaccine indicated above.
Signature
Date
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine
DD MM YYYY
(i.e., a mixed dose schedule) is considered off-label. For any off-label use of a vaccine a prescription is required.
HP7565 | 21.10.22
HNZ00034113 Appendix p46
Authorised prescriber (incl. medical practitioner, nurse practitioner or pharmacist prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer or
Novavax vaccination
to the person named on this consent form. (please circle one above)
Name
APC number
Signature
Date DD MM YYYY
For prescription requirements please see the relevant Policy Statement.
Information for Vaccinator
Details confirmed
Positive answer to any screening questions? Yes No
If yes, record information and advice given:
Informed consent obtained? Yes No
Date
/
/
Time
DD MM YYYY the 1982
Vaccine
Diluent
Pfizer only
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of
reconstitution
Paediatric Pfizer
0.2mL
Act
Pfizer/BioNTech
0.3mL
under
Novavax
0.5mL
Paediatric Pfizer Dose 1
Dose 2
Dose 3*
5-11 years
5-11 years
5-11 years
Booster 2
Pfizer
Dose 1
Dose 2
Dose 3*
Booster 1
For those eligible
12 years and above
12 years and above
12 years and above
16 years and above
16 years and above
Booster 2
Novavax
Dose 1
Dose 2**
Booster
For those eligible
12 years and above
12 years and above
18 years and above
18 years and above
* These doses are considered off-label use. ** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Vaccinator information
Observation area information
Details of any AEFI or observations recorded
Information
Name
Released CARM Report completed
Signature
Signature
Post vaccination information given
Departure time
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check with
the consumer.
Official
Name
Signature
Date DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
HNZ00034113 Appendix p41
COVID-19
vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
National Health Index number if known
Ethnicity (please tick one or more)
the 1982
NZ European Māori Samoan Cook Island Māori Tongan Niuean Chinese
Indian Other – please state
Consent statements
Act
I have read the fact sheet called ‘What you need to know about the COVID-19 vaccination’.
I know I will need to wait at least 15 minutes after the vaccination.
The benefits and risks of the COVID-19 vaccine have been explained to me.
under
The common and rare side effects of the COVID-19 vaccine have been explained to me.
I had enough time to ask questions and my questions were answered to my satisfaction.
I have received or photographed the fact sheets so I can refer to them after I leave the appointment.
• ‘What you need to know about the COVID-19 vaccination’
• ‘After the COVID-19 vaccination’
I was told how and when to seek assistance if I/ the person being vaccinated experience symptoms
that may be vaccine related.
I understand this vaccination information will be recorded and shared with my/the vaccinated
person’s regular healthcare provider.
Information
I consent to the COVID-19 vaccination being given.
Released
Signature
Date
DD MM YYYY
As parent / legal guardian / enduring power of attorney
I
am the parent, legal guardian or enduring power of
attorney, and agree to the COVID-19 vaccination of the person named above.
Relationship to person being vaccinated
Phone
Official
Signature
Date
DD MM YYYY
1 | English | COVID-19 vaccine consent form
HP7565 | 02.02.23
HP7565 COVID-19 vaccine consent form v73.indd 1
2/02/23 10:10 AM
HNZ00034113 Appendix p42
Doses requiring prescription
Prescriber (incl. medical practitioner, nurse practitioner or pharmacist prescriber)
Prescriber (incl. medical practitioner, nurse practitioner or pharmacist prescriber)
I confirm that I have explained the reasons for, the risks and benefits of the
Pfizer or
Novavax
v I confirm
accination tha
to t I have e
the per xplained the r
son named on easons for,
this consent the risk
form. s and benefits of the Pfizer or Novavax vaccination
Pr to the person named on
escriber’s name
this consent form.
MCNZ/APC number
Prescriber’s name
Signature
Date
DD MM YYYY
Signature
Vaccination site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check
with the consumer.
Name
Signature
Date
DD MM YYYY
the 1982
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
Vaccination record (for vaccinator use)
Consumer details confirmed Affirmative answer to any screening questions? Yes No
Act
If yes, record the detail and advice given
under
Verbal and written post vaccination information given
Informed consent obtained? Yes No
Pfizer
Dose 1
Dose 2
Dose 3
6 months - 4 years
Pfizer
Dose 1
Dose 2
Dose 3*
5 - 11 years
Pfizer
Dose 1
Booster 1
Booster 2
Dose 2
Dose 3*
For those eligible
12 years and over
16 years and over
16 years and over
Novavax
Dose 1
Booster 1
Booster 2
Dose 2**
Dose 3*
12 years and over
18 years and over
For those eligible
18 years and over
* These doses are considered off-label use. Off-label does not apply to those receiving a third dose as part of their 6 month-4 year vaccine course.
Information
** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Released
Vaccine details
Diluent
Pfizer only
Name of vaccine
Batch
Expiry
Dose
Site
Date
Time
Batch
Expiry
Time of
reconstitution
Vaccinator information
Observation period
Place of vaccination
Details of any AEFI or observations recorded
Official
CARM report completed
Name
Signature
Signature
Departure time
HP7565 COVID-19 vaccine consent form v73.indd 2
2/02/23 10:10 AM
HNZ00034113 Appendix p39
COVID-19
vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
National Health Index number if known
Ethnicity (please tick one or more)
NZ European Māori Samoan Cook Island Māori Tongan Niuean Chinese
the 1982
Indian Other – please state
Consent statements
I have read the fact sheet called ‘What you need to know about the COVID-19 vaccination’.
Act
I know I will need to wait at least 15 minutes after the vaccination.
The benefits and risks of the COVID-19 vaccine have been explained to me.
under
The common and rare side effects of the COVID-19 vaccine have been explained to me.
I had enough time to ask questions and my questions were answered to my satisfaction.
I have received or photographed the fact sheets so I can refer to them after I leave the appointment.
• ‘What you need to know about the COVID-19 vaccination’
• ‘After the COVID-19 vaccination’
I was told how and when to seek assistance if I/ the person being vaccinated experience symptoms
that may be vaccine related.
I understand this vaccination information will be recorded and shared with my/the vaccinated
person’s regular healthcare provider.
Released
Information
I consent to the COVID-19 vaccination being given.
Signature
Date
DD MM YYYY
As parent / legal guardian / enduring power of attorney
I
am the parent, legal guardian or enduring power of
attorney, and agree to the COVID-19 vaccination of the person named above.
Official
Relationship to person being vaccinated
Phone
Signature
Date
DD MM YYYY
1 | English | COVID-19 vaccine consent form
HP7565 | 16.02.23
HNZ00034113 Appendix p40
Doses requiring prescription
Prescriber (incl. medical practitioner, nurse practitioner or pharmacist prescriber)
I Prescriber
confirm tha (incl
t I ha . med
ve e ical practitioner
xplained the r
, nur
easons f se pr
or, actitioner
the risk
or pharmacis
s and benefits of t pr
the escriber
Pfizer or )
Novavax
vaccination to the person named on this consent form.
I confirm that I have explained the reasons for, the risks and benefits of the Pfizer or Novavax vaccination
Prescriber’s name
MCNZ/APC number
to the person named on this consent form.
Prescriber
Signature ’s name
Date
DD
MM YYYY
V Signat
accina ure
tion site clinical lead
When administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check
with the consumer.
Name
Signature
Date
DD MM YYYY
When a prescription is used, the prescriber must retain this form or a copy,
and hold securely as a medical record in accordance with local policy.
the 1982
Vaccination record (for vaccinator use)
Consumer details confirmed Affirmative answer to any screening questions? Yes No
If yes, record the detail and advice given
Act
Verbal and written post vaccination information given
Informed consent obtained? Yes No
under
COVID-19 vaccination primary course
COVID-19 vaccination boosters
Pfizer
Pfizer
Pfizer
Novavax
Pfizer
Novavax
Comirnaty (3mcg)
Comirnaty (10mcg) Comirnaty (30mcg) Nuvaxovid
Comirnaty (15/15mcg)
Nuvaxovid
Original/ Omicron BA.4/5
6 months - 4 years 5 – 11 years
12 years and over
12 years and over
16+ years for those eligible 16+ years for those eligible
Dose 1
Dose 1
Dose 1
Dose 1
Dose 1
Dose 1
Dose 2
Dose 2
Dose 2
Dose 2**
Dose 2
Dose 2
Dose 3
Dose 3*
Dose 3*
Dose 3*
* These doses are considered off-label use. Off-label does not apply to those receiving a third dose as part of their 6 month-4 year vaccine course.
Information
** A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Released
Vaccine details
Diluent (Comirnaty 3mcg and 10mcg only)
Name of vaccine
Batch
Expiry
Dose
Site
Date
Time
Batch
Expiry
Time of
reconstitution
Vaccinator information
Observation period
Place of vaccination
Details of any AEFI or observations recorded
Official
CARM report completed
Name
Signature
Signature
Departure time
1 | English | COVID-19 vaccine consent form
HP7565 | 16.02.23
HNZ00034113 Appendix p47
COVID-19
vaccination
consent form
Person
Surname
First name
Phone
Date of birth
Age
years
DD MM YYYY
Address
Medical Centre/GP
NHI
National Health Index number if known
Ethnicity (please tick one or more)
NZ European Māori Samoan Cook Island Māori Tongan Niuean Chinese
the
Indian Other – please state
1982
Consent statements
I have read the fact sheet called ‘What you need to know about the COVID-19 vaccination’.
I confirm that I/ the person being vaccinated have not tested positive for COVID-19 in the
Act
last 6 months.
I know I will need to wait at least 15 minutes after the vaccination.
under
The benefits and risks of the COVID-19 vaccine have been explained to me.
The common and rare side effects of the COVID-19 vaccine have been explained to me.
I had enough time to ask questions and my questions were answered to my satisfaction.
I have received or photographed the fact sheets so I can refer to them after I leave the appointment.
• ‘What you need to know about the COVID-19 vaccination’
• ‘After the COVID-19 vaccination’
I was told how and when to seek assistance if I/ the person being vaccinated experience symptoms
that may be vaccine related.
I understand this vaccination information will be recorded and shared with my/the vaccinated
person’s regular healthcare provider.
Released
Information
I consent to the COVID-19 vaccination being given.
Signature
Date
DD MM YYYY
As parent / legal guardian / enduring power of attorney
I
am the parent, legal guardian or enduring power of
attorney, and agree to the COVID-19 vaccination of the person named above.
Official
Relationship to person being vaccinated
Phone
Signature
Date
DD MM YYYY
1 | English | COVID-19 vaccine consent form
HP7565 | 31.03.23
HNZ00034113 Appendix p48
Doses requiring prescription
Prescriber (incl. medical practitioner, nurse practitioner or pharmacist prescriber)
I Prescriber
confirm tha (incl
t I ha . med
ve e ical practitioner
xplained the r
, nur
easons f se pr
or, actitioner
the risk
or pharmacis
s and benefits of t pr
the escriber
Pfizer or )
Novavax
vaccination to the person named on this consent form.
I confirm that I have explained the reasons for, the risks and benefits of the Pfizer or Novavax vaccination
Prescriber’s name
MCNZ/APC number
to the person named on this consent form.
Signature
Date
Prescriber’s name
DD
MM YYYY
Vaccination site clinical lead
W Signature
hen administering an off-label dose of vaccine, the clinical lead signs as an informed consent final check
with the consumer.
Name
Signature
Date
DD
MM YYYY
When a prescription is used, the prescriber must retain this form or a copy, and hold securely as a medical
record in accordance with local policy.
Vaccination record (for vaccinator use)
the 1982
Consumer details confirmed Affirmative answer to any screening questions? Yes No
If yes, record the detail and advice given
Verbal and written post vaccination information given Informed consent obtained? Yes No
Act
Confirmed consumer has not tested positive for COVID-19 in the last 6 months
CIR checked to ensure recommended dose interval before administration
under
COVID-19 vaccination primary course
COVID-19 vaccination additional dose
Pfizer
Pfizer
Pfizer
Novavax
Pfizer
Novavax
Comirnaty (3mcg)
Comirnaty (10mcg) Comirnaty (30mcg) Nuvaxovid
Comirnaty (15/15mcg)
Nuvaxovid
Original/ Omicron BA.4/5
6 months - 4 years 5 – 11 years
12 years and over
12 years and over
16+ years for those eligible
‡ 18+ years for those eligible
Dose 1
Dose 1
Dose 1
Dose 1
Dose
Dose
Dose 2
Dose 2
Dose 2
Dose 2
†
Dose 3
Dose 3*
Dose 3*
Dose 3*
* These doses are considered off-label use. Off-label does not apply to those receiving a third dose as part of their 6 month-4 year vaccine course.
† A second primary dose following another COVID-19 vaccine (i.e., a mixed dose schedule) is considered off-label.
Released
Information
‡ Those 12-15 years that meet severely immunocompromised criteria are recommended for an additional dose. This will require a prescription.
Vaccine details
Diluent (Comirnaty 3mcg and 10mcg only)
Name of vaccine
Batch
Expiry
Dose
Site
Date
Time
Batch
Expiry
Time of
reconstitution
Vaccinator information
Observation period
Place of vaccination
Details of any AEFI or observations recorded
Official
CARM report completed
Name
Signature
Signature
Departure time
1 | English | COVID-19 vaccine consent form
HP7565 | 31.03.23