Recommendation to Receive the Pfizer (ComirnatyTM)
COVID-19 Vaccine

Patient Details		
Surname: <<Patient Demographics:Surname>>	First name: <<Patient Demographics:First Name>>	
Date of birth: <<Patient Demographics:DOB>>	
Sex at birth: (Male, Female, Intersex, Unknown / prefers not to say) <<Patient Demographics:Gender>>	
Phone: (h) <<Patient Demographics:Phone (Home)>>  (m) <<Patient Demographics:Phone (Mobile)>>	Email: <<Patient Demographics:E-mail>>	
Home address: <<Patient Demographics:Address Line 1>>, <<Patient Demographics:City>>, <<Patient Demographics:State>>, <<Patient Demographics:Postcode>>  	
Medicare / Reference number: <<Patient Demographics:Medicare Number>>	 Expiry: <<Patient Demographics:Medicare Expiry Date>>	
Has this patient already received a dose of COVID-19 vaccine? 
* If vaccination status is unknown please check the AIR 	
If yes, brand of COVID-19 vaccine: (AstraZeneca, Pfizer (Comirnaty™), Other) 	
Date of first vaccination: 	
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. 
Please indicate below by using ‘X’	
	Cerebral Venous Sinus Thrombosis (CVST)	
	Heparin Induced Thrombocytopenia (HIT)	
	Idiopathic splanchnic (mesenteric, portal or splenic) venous thrombosis	
	Anaphylaxis, thrombosis with thrombocytopenia syndrome or other serious adverse event attributed to the first dose of the AstraZeneca COVID-19 vaccine*	
	Anaphylaxis to a component of the AstraZeneca COVID-19 vaccine*	
	Capillary leak syndrome	
	Current pregnancy or breastfeeding	
	Other approved medical contraindication to AstraZeneca COVID-19 vaccine (specify)*
(if yes, specify) 	
* It is advisable to speak with a Public Health Services Immunisation CNC to discuss the details of other serious adverse events or contraindications before signing this form to ensure that your patient has had the appropriate assessment to meet these conditions. More supporting documentation may be requested.	

Medical Practitioner details	
Full name: <<Doctor:Name>>	
Specialty: General Practitioner	
Practice name: <<Practice/Location:Name>>	
Contact number: <<Practice/Location:Phone>>	
Provider number: <<Doctor:Provider Number>>	
Signature: 	Date: <<Miscellaneous:Date (short)>>	

Please fax this completed referral form to (03) 6173 0821
Please note that submission of this form does not guarantee a Pfizer vaccine will be booked. The Tasmanian Immunisation Clinical team will review this referral and if appropriate, contact the patient to make a COVID-19 vaccine booking. Otherwise, we may be in contact to gather further details.	

Office use only	
Date received: 	Assessed on (date):	
Assessed by (name):	
Decision:  
☐ Pfizer indicated 
☐ Pfizer not indicated
☐ More information pending	Discussed with SMA/PHMO/registrar (name)*:	
Comments

	
*Note: all mixed dose schedules require discussion with the SMA