Immunisation History Request Form

* Mandatory Field

Personal Details
Family Name*
First Name*
Date of Birth*
(dd/mm/yyyy)
Email address*
Contact Phone Number*
Medicare Number*
Childhood Records
High School Records
Please advise the years attended Renmark High School*
Please Note
The Renmark Paringa Councils Immunisation Team will endeavour to provide a response within 5 working days on receipt of the immunisation request
If you see this, leave this form field blank.
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