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COVID-19 Booster Registration

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    Section 1: Personal Details. Complete this part for the person being vaccinated (PLEASE USE BLOCK CAPITALS)

    Personal Details

    Person’s Date of Birth

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

    Phone Number

    Email

    Is this appointment for your 1st Booster or 2nd?

    When was your the initial course for the vaccinations completed and which vaccine was received?

    When was your 1st Booster received? (Please note thats it is recommended for 6 months after the 1st booster but a minimum of 4 months is acceptable)

    Section 2: Please answer the following questions with a yes or no answer

    1.

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

    I) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®)COVID-19 vaccine, OR

    II) to any of the vaccine ingredients, including polyethylene glycol known as PEG?

    If yes, they cannot get this vaccine. If no, GO TO NEXT QUESTION.

    1b.

    Have you ever had a serious allergic reaction (anaphylaxis) to Trometamol (a contrast dye used in MRI radiological studies)?

    If yes, they cannot get the Moderna (Spikevax®) vaccine. But they can have a different vaccine. Talk to your GP. If no, GO TO NEXT QUESTION.
    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 they are allergic to polyethylene glycol

    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 TO NEXT QUESTION.

    3.

    Have they ever had:

    I) Mastocytosis (rare condition caused by an excess number of mast cells gathering in the body's tissues) OR

    II) idiopathic anaphylaxis. This is a condition diagnosed by an immunologist. OR

    III) a serious allergic reaction (anaphylaxis) due to food, medication or venom from an insect or animal?

    If yes, they can still get the vaccine, BUT, they should be observed for 30 minutes after they are vaccinated. GO TO NEXT QUESTION. If no, GO TO NEXT QUESTION.

    4.

    Have they had myocarditis (inflammation of the heart muscle) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine?

    If yes, they cannot get this vaccine. If no, GO TO NEXT QUESTION.
    5.

    Have they had pericarditis (inflammation of the lining around the heart) after having a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine?

    If yes, GO TO QUESTION 5b. If no, GO TO NEXT QUESTION.
    5b.

    Since they had pericarditis (inflammation of the lining around the heart) after a previous dose of the Moderna (Spikevax®) or Pfizer/BioNTech (Comirnaty®) COVID-19 vaccine, a specialist doctor must approve they get this vaccine. Has their COVID-19 vaccination been approved by a specialist doctor?

    If yes, GO TO NEXT QUESTION. If no, they cannot get this vaccine.
    6.

    Have they tested positive (with a PCR test) in the last 6 months for COVID-19 since they were fully vaccinated with a course of COVID-19 vaccine?

    If yes, they should delay getting the vaccine until it has been at least 3 months from their first positive PCR test or their date of diagnosis.
    7.

    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 their vaccinator about their condition.
    8.

    Has this person already received an additional dose or booster dose (after their initial primary vaccination course) in the last 3 months?

    If yes, they do not need a booster dose. If no, continue to next question
    9

    Is this person pregnant?

    If you are pregnant the COVID-19 vaccine is recommended for you. You can get the vaccine at any stage of pregnancy.

    Section 3: One of these options is appropriate when establishing consent (please tick as appropriate)

    1

    The individual has consented to the vaccination for COVID-19 and has been provided with written information, OR

    2

    The individual does not agree with COVID-19 vaccination and should not be vaccinated, OR

    3

    The individual cannot consent and they are being vaccinated for COVID-19 according to their benefit and will and preference, AND

    The above is recorded in their healthcare record and includes information about any consultation that has taken place to help determine their will and preference.

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