Certificate of Immunisation Request |

Details of the person immunised

Name*

First Last

Please enter any other name you have been known by, if applicable.

First Last

Date of Birth*

List of Schools and the Clinic

List of locations where immunisations may have been administered. Please check at least one location. Please note: If the school or clinic that you attended is not in the list, then we do not hold the immunisation record. Please contact the relevant Council of the school or clinic you attended directly.

Select at least one of the following locations:*

I am requesting the release of the immunisation records for the below:*

Please select one option.

If this is for your child's records, please enter your name here

First Last

Contact Details

Enter the address you would like the Certificate of Immunisation sent to - leave the email address blank if you would like a hard copy posted.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Phone*

Privacy Statement

On application, client details will only be released to the client directly, or if the client is under 18 years of age, to the client's lawful guardian/s. In cases where the application is made by a person other than the client, documentation may be requested to confirm the applicant's relationship to the client.

Declaration*

I declare that the information I have provided is, to the best of my knowledge, true and correct.

Our aim is to provide you with your immunisation records as quickly as possible. You should receive your Certificate of Immunisation within two days of your request.

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Certificate of Immunisation Request

Immunisation Form

Details of the person immunised

List of Schools and the Clinic

Contact Details

Privacy Statement