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

---