Immunisation History Request Form

Immunisation History Request Form

* Mandatory Field

Personal Details
Family Name*
First Name*
Date of Birth*
(dd/mm/yyyy)
E-mail Address*
Home Phone Number
Mobile Number
Medicare Number*
Number on Card*
Please Advise the Names of the Schools Attended in the City of Mitcham
Date*
(dd/mm/yyyy)
Please Note

Vaccines offered through the school based immunisation programme are Hepatitis B, Meningococcal C, Human Papilloma Virus, Boostrix {dTp}, ADT and Varicella

The City of Mitcham’s immunisation team will endeavour to provide a response within 24 – 48 hours on receipt of the immunisation request.

If you see this, leave this form field blank.

Contact Us

Tel 08 8372 8888

Fax 08 8372 8101

Email Us

Opening Hours

Monday to Friday 9am to 5pm

Locate Us

PO Box 21

Mitcham Shopping Centre

Torrens Park SA 5062

131 Belair Road

Torrens Park SA 5062

Share this page
Top