Immunisation catch-up schedule request

Please complete this form if you want to request a vaccination catch–up schedule.

Your child’s details

Date of birth (required)

Medicare number (required)

First name (required)

Last name (required)

Address (required)

Please upload scanned copies of your child’s immunisation history records (required)

Upload files

Child's records must be in English or have a translated copy.
Maximum 3 files.
20 MB limit.
Allowed types: gif, jpg, png, bmp, pdf.

Your details

First Name (required)

Last name (required)

Address (required)

Phone (required)

Please enter your mobile or home number. eg. 03 9999 9999 or 0499 999 999

Email (required)

Relationship to child (required)

Assessment outcome

How do you want to be contacted? (required)

Phone

Post

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