COVID-19 VACCINATION CONSENT FORM

The COVID-19 vaccine is administered to control the spread of COVID-19 in this country. When more people are vaccinated, more people will develop antibodies and subsequently reduce the risk of a serious COVID-19 infection. Indirectly, we can protect vulnerable groups that cannot be vaccinated.

The Special Meeting of the Muzakarah Committee of the National Council for Islamic Religious Affairs that convened on 3 December 2020 has stipulated that the requirement for use of the Covid-19 vaccine is just, and must be taken by the groups identified by the government.

The COVID-19 vaccination requires one (1) or two (2) doses depending on the type of vaccine. This vaccine is usually injected into the shoulder muscles, except in certain circumstances. The type of vaccine that is given will depend on the vaccine supply at the time.

This COVID-19 vaccination could cause mild side effects and other side effects that will be reported from time to time.

HEALTH HISTORY (Please complete)

Have you :

a. Suffered severe side effects (such as seizures, fainting and hospitalisation) after receiving any immunisation
in the past?

b. Had any history of severe allergies?

c. Are you currently pregnant or planning to conceive? (for women)

d. Are you currently breast-feeding a baby? (for women)

I read / was informed about the COVID-19 vaccine information including the purpose and method of vaccination as stated in the COVID-19 Vaccine Information sheet for Vaccine Recipients.

With this, I understand that :

1. taking this COVID-19 vaccine may cause reactions and side effects as stated in the vaccine information;
2. I am responsible for the risks that could occur as a result of my decision / action because the benefit of the vaccine far outweighs the side effects;
3. this vaccine does not fully guarantee that I will not be infected by COVID-19 in the future;
4. by signing this agreement to receive this COVID-19 vaccine, I willingly agree to finish the dosage requirements as scheduled.

I, _________________________________ MyKad / Police / Military Number __________________
* AGREE / DO NOT AGREE to receive the _______________ COVID-19 vaccination for * myself / * my parent / * my ward named __________________ MyKad / Police / Military Number __________________

Signature of beneficiary / heir                Signature of Witness

Name :                                                       Name :
Identity Card Number :                            Identity Card Number :
Date :                                                         Date :

* cross out what is not relevant

Important note : For more information on the COVID-19 Vaccine, refer to the COVID-19 Vaccine Information sheet for Vaccine Recipients.

Thank you for your cooperation. Please return this form to the clinic.