This is an HTML version of an attachment to the Official Information request 'NZ Government Definition of Informed Consent'.

Appendix 1
Keep up good habits
What health information 
do I need to share?
Wear a mask or face covering 
If you have had an allergic reaction to any vaccine 
when out and about.
or injection in the past, please tell your vaccinator. 
Use the NZ COVID Tracer app 
If you are taking any medications or have a
to keep a record of where 
bleeding disorder, talk to your health provider first.
ACT 1982
you’ve been.
Stay home if you are sick and 
Getting the right 
contact Healthline or talk to your 
information matters
parent or guardian about getting 
Be aware of incorrect or second-hand 
a test.
information on social media and other places. 
Wash your hands or 
You can get accurate and trusted information at:
use hand sanitiser. 
•  COVID Vaccination Healthline on
0800 28 26 29 (8am to 8pm, 7 days a week)
INFORMATION 
•  Covid19.govt.nz
Cough and sneeze 
into your elbow.
•  Health.govt.nz/covid-vaccine
•  karawhiua.nz
•  or talk with your doctor.
Keep physically 
distanced.
How can I get the 
COVID-19 vaccine?
If you are 12-15 you might want to ask your parent 
Is the vaccine safe?
or guardian to help book your appointment.
The Pfizer vaccine has been thoroughly 
Visit BookMyVaccine.nz where you can either 
assessed for safety by our own Medsafe experts. 
book an appointment or find out where a drop-in 
Medsafe only grants consent for using a vaccine 
Your COVID-19 
centre is (you do not need an appointment – just 
in Aotearoa once they’re satisfied it has met 
turn up!).
strict standards for safety, efficacy and quality. 
vaccination
If you’re unable to book online, you can cal  
This is the same process used to assess other 
the COVID Vaccination Healthline on  
medicines, like the flu vaccine. 
0800 28 26 29 (8am to 8pm, 7 days a week) and 
Everything you need to know 
we’ll make the booking for you and answer any 
about the Pfizer vaccine
There have been no shortcuts taken in 
questions. Interpretation services are available 
granting approval. 
if you need them.
The Pfizer vaccine has been used successful y 
RELEASED UNDER THE OFFICIAL 
by mil ions worldwide. 
It continues to be monitored for safety.
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Appendix 1
When you get vaccinated, you’re 
Getting your vaccination
Rare side effects
not just protecting yourself. You’re 
A healthcare worker will do a health 
Allergic reactions
check with you and answer your 
There are some side effects that are more 
also doing your bit by reducing the 
questions.
serious but rare, like a severe al ergic reaction 
risk of passing on COVID-19 to your 
or anaphylaxis. This is the reason people 
You can say yes or no to getting 
are observed for around 15 minutes post 
the vaccine. If you are 12-15, we 
whānau, friends and community. 
vaccination. Vaccinators are trained to manage 
recommend discussing the vaccination 
these reactions i
ACT 1982 f they occur.
with your whānau or a trusted support 
The COVID-19 vaccine is free and 
person, and your parent or caregiver 
Myocarditis and Pericarditis
available to everyone aged 5 years 
can provide consent if you prefer.
Myocarditis is inflammation of the heart 
and over in Aotearoa – however 
muscle, while pericarditis is inflammation of the 
A fully trained health care worker will 
tissue forming a sac around the heart. These 
give you the vaccine in your upper 
the information contained in this 
conditions are usual y caused by viral infections 
arm. You will need to relax and sit 
(including COVID-19), but they are also very rare 
still. You can look away or close your 
brochure is only for those aged 12 
and serious side effects of the Pfizer vaccine.
eyes if you are feeling nervous.
and over.
Symptoms of myocarditis or pericarditis linked 
INFORMATION 
You will need to stay for at least 
to the vaccine general y appear within a few 
15 minutes to make sure you are ok.
days, and mostly within the first few weeks after 
having the vaccine. If you get any of these new
Once a health care worker is confident 
symptoms after your vaccination, you should 
that you’re fine and you are feeling ok, 
seek medical help, especial y if these symptoms 
you can carry on with your day.
don’t go away:
After your vaccination
•  tightness, heaviness, discomfort or pain 
in your chest or neck
You will be asked to get your second dose of the 
•  difficulty breathing or catching your breath
vaccine after a gap of three weeks or more. If 
you are over 18, you should get a booster dose a 
•  feeling faint or dizzy or light-headed
few months later to make sure you have the best 
•  fluttering, racing or pounding heart, 
protection against COVID-19.
or feeling like it is ‘skipping beats’.
If you feel unwell or are worried about any side 
If you feel any of these symptoms in the days or 
What is a vaccine?
effects, speak with your trusted health professional.
weeks after the vaccine, you should see a doctor.  
There will be no charge for the consultation. 
Vaccines protect you and help stop you getting 
Potential side effects 
You can also call Healthline on 0800 358 5453 
sick. You may have already had some vaccines 
of Pfizer vaccine
anytime to get advice.
such as the flu ‘jab’ or a measles vaccine. 
How I might feel
If you are very worried about your health, call 
The COVID-19 vaccine works by teaching your 
You may experience some side effects, such 
111, and make sure you tell them you’ve had a 
body to fight the virus. The vaccine cannot give 
as muscle aches, pain at the injection site or 
COVID-19 vaccination, or have or had COVID-19 
RELEASED UNDER THE OFFICIAL 
you COVID-19.
headaches. For most people these are mild 
so they can assess you properly.
effects that may not last long or impact on their 
You can report any side effects you experience 
day-to-day activities. 
at report.vaccine.covid19.govt.nz
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Appendix 1
COVID-19 vaccine: 
After your Pfizer 
vaccination 
This factsheet covers the Pfizer vaccine only. Information on the 
AstraZeneca vaccine and its potential side effects can be found at 
health.govt.nz/covid-19-vaccines or 0800 358 5453
How might I feel after I get 
ACT 1982
This is the reason people are observed 
the vaccine
for around 15 minutes post vaccination. 
Vaccinators are trained to manage these 
Like all medicines, you might experience 
if they occur.
some mild side effects for up to 1–2 days after 
getting your Pfizer vaccination and booster, 
Myocarditis and pericarditis
this includes your first or second dose or 
Myocarditis is inflammation of the heart 
booster. Most side effects do not last long  
muscle, while pericarditis is inflammation of 
and for many people they will not impact on  
the tissue forming a sac around 
INFORMATION  the heart. 
day-to-day activities. 
These conditions are usually caused by viral 
The most common reported reactions are:
infections (including COVID-19), but they are 
•  pain or swel ing/redness at the injection site
also very rare and serious side effects of the 
•  feeling tired or fatigued
Pfizer vaccine. 
•  headache
Symptoms of myocarditis or pericarditis 
•  muscle aches and/or joint pain
linked to the vaccine generally appear within 
•  chills/fever
a few days, and mostly within the first few 
•  nausea.
weeks after having the vaccine. If you get any 
of these new symptoms after your vaccination, 
If you feel uncomfortable you can:
you should seek medical help, especially if these 
•  place a cold, wet cloth or ice pack on 
symptoms don’t go away: 
the injection site for a short time
•  tightness, heaviness, discomfort or 
•  rest and drink plenty of fluids
pain in your chest or neck 
•  take paracetamol or ibuprofen.
•  difficulty breathing or catching your breath 
Seek advice from your health care professional 
•  feeling faint, dizzy or light-headed 
if you are unsure or your symptoms worsen.
•  fluttering, racing or pounding heart, 
Rare side effects
or feeling like it is ‘skipping beats’. 
RELEASED UNDER THE OFFICIAL 
Allergic reactions
If you feel any of these symptoms in the days 
or weeks after the vaccine, you should seek 
There are some side effects that are more 
medical help. There will be no charge for the 
serious but rare, like a severe allergic reaction 
consultation.
or anaphylaxis. 
1   |   English   |   After your vaccination
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Appendix 1
Vaccines protect us
Vaccines help protect people of all ages 
against other infectious diseases too, like 
measles and flu. Check you and your whānau 
are up to date with your vaccinations by 
You can also call Healthline on  
talking with your health care provider. 
0800 358 5453 anytime to get advice. 
A gap of at least seven days is recommended 
If you have an immediate concern about 
between having the COVID-19 vaccine and 
your safety, call 111, and make sure 
the Zostavax (shingles) vaccine. 
you tell them you’ve had a COVID-19 
There are no concerns around the timing of 
vaccination, or have or had COVID-19 
other vaccines such as flu or MMR (measles, 
so they can assess you properly. 
mumps and rubella). You do not need to 
ACT 1982
You can report any side effects you 
delay any of these vaccinations. 
experience at: 
Visit health.govt.nz/immunisation 
report.vaccine.covid19.govt.nz
for more information.
After your vaccination, it's still important to:
INFORMATION 
Stay home and get 
Use the NZ COVID Tracer app to 
a test if you’re sick
scan QR codes to record your 
visits & turn on Bluetooth tracing
Keep indoor spaces well 
Wear a mask when 
ventilated and clean shared 
you’re out and about
surfaces regularly
Wash or sanitise 
Keep physically distanced
your hands
Cough and sneeze 
into your elbow
RELEASED UNDER THE OFFICIAL 
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Appendix 1
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
ACT 1982
bleeding disorder 
If you are receiving Novavax, 
•  If you’ve ever had capillary leak 
•  If you’ve had a previous severe 
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.
  I have had a chance to ask questions and they were answered to my satisfaction. 
INFORMATION 
  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.
Name of parent or legal guardian   
Phone          
Relationship to person being vaccinated
Signature
Date          
Tick the vaccine dose that applies: 
Dose 1
Dose 2
Paediatric Pfizer
Dose 3
5-11 years
5-11 years
5-11 years
RELEASED UNDER THE OFFICIAL 
Dose 1
Dose 2
Pfizer
Dose 3*
12 years and above
12 years and above
12 years and above
Dose 1
Dose 2**
AstraZeneca
Dose 3*
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.
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Appendix 1
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  
PfizerAstraZeneca 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
ACT 1982
Name of vaccine
Date
Time
Dose
Site
Batch
Expiry
Batch
Expiry
Time of 
reconstitution
Paediatric Pfizer
0.2mL
Pfizer/BioNTech
0.3mL
AstraZeneca
0.5mL
Novavax
0.5mL
INFORMATION 
Dose 1
Dose 2
Paediatric Pfizer
Dose 3
5-11 years
5-11 years
5-11 years
Dose 1
Dose 2
Pfizer
Dose 3*
12 years and above
12 years and above
12 years and above
Dose 1
Dose 2**
AstraZeneca
Dose 3*
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. 
Vaccinator information
Observation area information
Details of any AEFI or observations recorded
Name 
CARM Report completed
Signature
Signature  
    
Post vaccination information given 
Departure time  
RELEASED UNDER THE OFFICIAL 
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   
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.

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