Request for Immunisation Records

Request for Immunisation Information

Please fill out your contact information below.

Name*

First Name

Last Name

Address*

Address Line 1

Address Line 2

City

State

Postcode

Home Phone*

Work Phone

Email*

Medicare Number*

Date of birth*

Please list any changes that may have occurred to Surname or First Name that will assist with our search:

Person applying for Record: If the same, write AS ABOVE

Applicant’s relationship to the above mentioned (Parent/Guardian) :

Preferred method to receive record

Email Post

I declare that I am the person nominated on this form or the parent/guardian of the child nominated on this form*

Yes

We are not able to provide records of immunisations given by doctors or other providers.

For children under the age of 14 years, their infant immunisation records are available by contacting the Australian Immunisation Register (AIR) on 1800 653 809.

If you are over the age of 18 years you will need to apply for the information yourself.

Please allow ten (10) days from receipt of request for retrieval of records. For any enquiries, please contact the Immunisation Team on 4408 6590.

Privacy Statement: The personal information requested on this form is being collected by the Council for the purpose of accessing immunisation information. The personal information will be used solely for the primary purpose and will not be available to third parties.