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EOI - Primary Care Vaccinations
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* Indicates required question
Email
*
Your email
Which dose of vaccine?
*
1st Dose
2nd Dose
Booster
Name of School
*
Wyndham Park Primary School
Gladstone Views Primary School
Meadow Heights Primary School
Mossfiel Primary School
Gladstone Park Primary School
Jennings Street School
Western Autistic School
Rosamond Special School
Yarraville Special Developmental School
Coburg Special Developmental School
Glenroy Specialist School
St Andrew’s School
Manorvale Primary School
Glenallen School
Student Full Name
*
Your answer
Date of birth (DOB)
*
MM
/
DD
/
YYYY
Address
*
Your answer
Mobile Number for Parents/Guardian (04XX XXX XXX)
*
Your answer
Medicare Card Number and Reference Number
*
Your answer
Any allergies or medical conditions
Yes
No
Other:
Clear selection
Any serious reaction to a vaccine or medication?
*
Yes
No
Language spoken at home
*
Your answer
I confirm that:
*
I am the child’s parent, guardian or substitute decision-maker
I have the authority to provide consent for this child and I agree to the child named above receiving the Pfizer COVID-19 vaccine.
Required
Parent/guardian/substitute decision maker name:
*
Your answer
Send me a copy of my responses.
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