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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.
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Contact:
City of Mitcham -ABN 92 180 069 793
131 Belair Road, Torrens Park SA 5062
T: +61 8 8372 8888 | F: +61 8 83728101
E: mitcham@mitchamcouncil.sa.gov.au
Last date modified: 2017-11-23T12:16:57
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