- Intercare

Pre-Vaccination Screening and Consent for COVID-19 Vaccination

You have selected to receive a COVID-19 vaccine to prevent Coronavirus Disease 2019 (COVID-19). The following information will help your healthcare provider identify and address potential risks related to the vaccine. If a question is unclear, please ask your healthcare provider to explain it. If you answer “Yes” to any question, it does not necessarily preclude you from being vaccinated, but your healthcare provider may need to ask you additional questions.

Unfortunately our vaccination centres are not operating at this stage.

The form below should only be used when instructed on the day of the vaccination at the vaccination centre.

Your Details

First Names

Surname

ID Number

Physical Address

Cell Number

Email Address

Medical Aid Name

Medical Aid Number