Vaccination Record Card for Health Care Workers and Students &, NSW GOVERNMENT Personal Details ( ease Please refer to instructions on three Dr Full Moon Milky Way General Practice Southern Cross Drive Outer Galaxy NSW 2099 Provider No: 1234567A Tpa vacclne) m4 JLI r2rn I Dr Full Moon Milky Way General pracrice Southern Cross Drive Outer Galaxy NSW 2099 Provider No: 12345674 Dr Full Moon Milky Wa1 Ceneral Practice Southern Cross Drive Outer Galaxy NSW 2099 Provider No: 1234567.4 OR core antibody Dr Full Moon Milky Way General Practicc Southern Cross Drive Outer Galaxy NSW 2099 Provider No: 1234567,4 Dr Full Moon Milky Way General Practice Southern Cross Drive Dr Full Moon Outer Galaxy NSW 2099 Provider No: 1234-567,4 Milky Way General Practice Southern Cross Drive Outer Gal axy NSW 2099 ProviderNo: I234567A 7f z/t-r,/ Surname G Azr N c., Given names Address C-l Siate:gg.; J p/cottJ: 'CCIO Date of BirthJ e)D\co \ o(^)c) Staff/student lD Email qA/r^q c;".-: gt .a e.Av. dr-r{ Contact numbers Mo co aco iO Work i) d*)') dooo Medicare Number € >1r1X) aOLpA{) Position on card: Cl Expiry date:q1 O/€!) - _ Adult formulation diphtheria, tetanus, acellular pertussis (wI Dose l rlrl )iLl kc=;l-&'tL3lYt ) nY\ Booster 1O years after previous dose Hepatitis B vaccine (age appropriate course of C-\ Dose I Booster dose after to Dose 2 \ Tick for adolescent ltr\a, I h+f>r c t ,=,u h I blz--i Dose 3 t 2o. '-l hllfr,/-lt-r*N\ AND 2a4 Resu/t mlU/mL OR Sero ogy ant -HBc Positive Negative 2-e,2-/ Measles, Mumps and Rubella (MMR) vaccine (2 doses [4MR vacctne at ieasf 1 month apart OR pasttive seroloa Dose l \ I ll zou Ktgt(. \)z /+ k(,"1?c- I tz/\ Dose 2 Booster if required OR Serology Meas es lgG Result Serology Mumps lgG Result Serology Rubella (include numerical value and immunity status as per lab report: Positive,/ Negative /Low level / Equivocal / Booster required) lgG Result Varicella vaccine (age tmmunitv to chtckenpox approprlate course of vacclnatlon OP posrtlve serology OR AIR history statement that records natural Dose I if given prior to l4 vears Dose 2 Booster if required OR I Serology Varicella 2ctL1 lgG Result OR Australian lmmunisation Register (AlR) History Statement that records natural immunity to chickenpox AIR Statement Slghted YES NO Dr Full Moon Milky WaY General Practice Soulhern Crclss Drivc Outer GalaxY NSW 2099 Provider No: 1234567A frv \41u1 I Batch No. (where possible) or Brand name Off icia I Certif ication by Vacci nation Provid er (c I i n i c,/ Vaccine Date to each entry) Revised February 2O21 1/z er^A€ aOOOOc) i 2$L\ z lV tr Serology: anti-HBs (NLrmerical rralr rc) I rlz-ozt Resu/) iO,Ajntu/mt I I 2ifZ) I