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Appendix 9: Consumer vaccination statement template
Note: Refer to the Australian Immunisation Handbook 10th edition 2013 www.immunise.health.gov.au
Pharmacy logo
CONSUMER VACCINATION STATEMENT
Consumer details
Name
Date of birth
Phone
Email
Address
Medicare no.
AUTHORISED IMMUNISER
Name
Contact details
Signed
Date
VACCINATION(S)
Infectious disease
Brand name
Dose
Site of administration
Batch number
Date of vaccination
Right arm
Time
Left arm
Right leg
Left leg
Date of next vaccination (if required)
Infectious disease
Brand name
Dose
Site of administration
Batch number
Date of vaccination
Right arm
Time
Left arm
Right leg
Left leg
Date of next vaccination (if required)
Infectious disease
Brand name
Dose
Site of administration
Batch number
Date of vaccination
Right arm
Time
Left arm
Right leg
Left leg
Date of next vaccination (if required)
Infectious disease
Brand name
Dose
Site of administration
Batch number
Date of vaccination
Right arm
Time
Left arm
Date of next vaccination (if required)
PHARMACY DETAILS
Name
Address
Phone
30
Right leg
Email
Practice guidelines for the provision of immunisation services within pharmacy I © Pharmaceutical Society of Australia Ltd.
Left leg
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