Date of Birth
Phone contact number
Date you are booked in for your vaccine
Are you Aboriginal and/or Torres Strait Islander?
Yes, Aboriginal onlyYes, Torres Strait Islander onlyYes Aboriginal and Torres Strait IslanderNoPrefer not to answer
Next of kin Name
I am the patient’s guardian or substitute decision-maker, and agree to COVID-19 vaccination of the patient named above
Guardian/substitute decision-maker’s name