Request for Immunisation Records Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields Request for Immunisation Information Please fill out your contact information below. Name* First Name* Last Name* Address* Address Line 1 Address Line 2 City Australian Capital Territory New South Wales Northern Territory Queensland South Australia Tasmania Victoria Western Australia 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. Previous← Next→ Enter your save and resume password Cancel Confirm
