Recommendation to Receive the Pfizer (ComirnatyTM) COVID-19 Vaccine	(Affix identification label here)

URN: 
Family name: <PtSurname>
Given name(s): <PtFirstName>
Address: <PtAddress>
Date of birth: <PtDoB>
Sex: <PtSex>
	
Patient Details	
Surname: <PtSurname>	
First name: <PtFirstName>	
Date of birth: <PtDoB>	Sex: <PtSex>	
Contact number - Home: <PtPhoneH>   Work: <PtPhoneWk>   Mobile: <PtPhoneMob>	
Home address: <PtAddress>	
Medicare number: <PtMCNo>   Ref.: <PtMCLine>   Exp.: <PtMCExpiry>
Leave blank if patient does not have a Medicare number	

The patient noted above has a history of the following medical condition(s) and it is recommended they receive the Pfizer (ComirnatyTM) COVID-19 vaccine according to current ATAGI advice.
<Cerebral Venous Sinus Thrombosis (CVST)> Cerebral Venous Sinus Thrombosis (CVST)
<Heparin Induced Thrombocytopenia (HIT)> Heparin Induced Thrombocytopenia (HIT)
<Idiopathic splanchnic (mesenteric, portal or splenic) venous thrombosis> Idiopathic splanchnic (mesenteric, portal or splenic) venous thrombosis
<Anti-phospholipid syndrome with thrombosis> Anti-phospholipid syndrome with thrombosis
<Anaphylaxis, thrombosis with thrombocytopenia or other serious adverse event attributed to the first dose of the AstraZeneca COVID-19 vaccine> Anaphylaxis, thrombosis with thrombocytopenia or other serious adverse event attributed to the first dose of the AstraZeneca COVID-19 vaccine
<History of anaphylaxis to a component of the AstraZeneca COVID-19 vaccine> History of anaphylaxis to a component of the AstraZeneca COVID-19 vaccine
<Other approved medical contraindication to AstraZeneca COVID-19 vaccine. Please note that HHS vaccination clinics may require further information to assess eligibility and your patient may not be vaccinated on the day of presentation if this is unavailable (attach further supporting documents as necessary)> Other approved medical contraindication to AstraZeneca COVID-19 vaccine. Please note that HHS vaccination clinics may require further information to assess eligibility and your patient may not be vaccinated on the day of presentation if this is unavailable (attach further supporting documents as necessary)	
Medical Practitioner: <DrName>	
Practice name: <Practice>	
Contact number: <UsrPhone>	Provider number: <DrProviderNo>	
Signature: 
	Date: <TodaysDate>	
Instructions for the Patient
Keep this completed form safe.You will be required to present this form on arrival to the vaccination clinic.	
Medical practitioners should retain a copy of the completed form within the patient's medical record.