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COVID-19 Vaccination Consent Form for 12 – 15 year olds

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    Section 1: Personal Details Complete this part for the young person.

    Personal Details

    Young 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

    Further Details

    Nationality:

    Ethnicity:

    Section 2: GP Details

    Section 3: Answer Questions

    1.

    Has this young 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 they 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 the Moderna (Spikevax®) vaccine. But they can have a different vaccine. Talk to your GP. 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 serious allergic reaction (anaphylaxis) with no known cause. 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 obs erved 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

    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 vaccinat ion been approved by a specialist doctor?

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

    Have they tested positive for COVID-19 within the last 4 weeks?

    If yes, they should delay getting a vaccine until they have recovered from COVID-19 and it has been at least 4 weeks since they tested positive or developed symptoms, or 4 weeks from their first positive PCR test if they did not have symptoms.
    7.

    Does this young 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.

    Only answer if this young person is female. Are they pregnant?

    If yes, go to 8b
    8b.

    Are they less than 14 weeks or more than 36 weeks pregnant?

    If yes, they cannot get vaccinated at this time. They may be able to get vaccinated when they are between 14 and 36 weeks pregnant. They should talk to their GP, midwife or obstetrician.

    If no, they can get vaccinated, but this is only as long as they have spoken with their midwife, obstetrician or doctor about the risks and benefits of getting the vaccine. Before being vaccinated they should confirm that they are at the correct stage of pregnancy to get the vaccine.

    Please select your local pharmacy

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