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
2 | English | After your vaccination
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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.
HP7565 | 4 May 2022
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
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
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.
Document Outline
