We are hopefully going to start the covid 19 vaccinations for the over 70's . The first tranche will be 85+ and going down from there. Can you please either copy and paste or request the consent form from ballybvax@protonmail.com . Please print & get it signed and sent back to us either at the surgery or to ballybvax@protonmail.com as we will not be able to do in clinic. If you do not have access to a printer you can collect a form between 12-12.30. However we are trying to limit increased footfall while in level 5 so please socially distance
consent form
The Covid 19 Vaccination Consent Form (Over 70s)
The COVID-19 vaccination will reduce the likelihood of being affected with COVID-19 disease. Like all drugs, no immunisation is 100% effective. It will also take a few weeks for the body to mount a protective response from the vaccine. You may still get COVID-19 despite the vaccination, but this should lessen the severity of any infection.
The vaccine will not give you COVID-19 infection, and two doses will reduce your chance of becoming seriously ill. You will still need to follow the public health guidance for the foreseeable future, most importantly soon after vaccination (before the body is fully protected), including wearing the correct personal protection equipment ( e.g masks as needed) and social distancing
You will receive either Comirnaty ( Pfizer/Biontech) or Covid 19 Moderna vaccine. Both of these are mRNA vaccines and have been chosen as they provide well over 90% efficacy in trials. This is because the over 70s are at higher risk and so will hopefully provide greater protection to this population . The schedule will be for 2 vaccinations
Common side effects may include pain and swelling at the injection site, tiredness, headache, muscle and joint pain, chills and fever. Please inform if you have ever had anaphylaxis.
Information on Covid 19 Vaccination can be found at COVID-19 Vaccines - Manufacturers' patient information leaflets - HSE.ie
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Full name
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Date of birth |
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Address
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Mobile number |
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GMS/DVC No.
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PPS No. if no card |
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Next of kin/emergency mobile
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GP name and address (if not Dr Maharg)
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I consent to full course of covid 19 vaccination □
Signed _____________
Date _____________