Immunisation

Immunisation Records Request Form – Gold Coast Public Health Unit

Please complete a form for each client for whom an immunisation record is requested.

Required fields are marked with an asterisk (*).

I have checked AIR as instructed and cannot access the records I require. *

I am/my child is a current or previous Gold Coast resident, student or employee and requires an immunisation record. *

Records may take up to 3-5 working days to be collated and returned

Client Details

Client's Surname *

Client's Given Name/s *

Client's date of birth *

Day Month Year

Medicare Number

Reference Number

Current Home Address *

Previous Gold Coast Address

Secondary Schools attended

(Medicare Number and Reference Number are very important to be used for finding historical records and identifying correct information for the right person)

Requestor's details

Requesting person's full name (if different to above)

Relation to client *

Parent
Legal Guardian
Self

Best contact phone number *

Email address *

Email address confirm *

Immunisation records to be sent to

Australia Immunisation Register and I will download the immunisation history statement from my 'Medicare online account' through myGov or the Express Plus Medicare mobile app
nominated medical centre/immunisation provider below and I will contact them to collect a copy

Medical centre/Immunisation provider name

Medical centre/Immunisation provider phone number

Privacy notice

Personal information collected by Gold Coast Public Health is handled in accordance with the Information Privacy Act 2009. Gold Coast Public Health is collecting information in relation to your personal details and immunisation record in order to assist us to provide you with accurate and up-to-date vaccination records.

All personal information will be securely stored and only accessible by staff members authorised to access your record. This type of personal information may be shared with your general practitioner or other vaccine service providers for the purpose of ensuring your vaccination records are accurate and those services providers concerned with your care are able to contact you in the event you may require further treatment or advice. The Information Privacy Act 2009 sets limits on transferring personal information overseas and therefore if you are overseas we may not be able to send history via email.

Your personal information will not be disclosed to other third parties without consent, unless Gold Coast Public Health is required by law.

For information about how Gold Coast Public Health protects your personal information, or to learn about your right to access your own personal information, please see Queensland Health records and privacy information.

Last updated: 8 January 2025