Immunisation Record

For ALL children aged 16 and under registering with the surgery, please provide details of your child’s immunisations. These should be recorded in your child’s red Health Record Book. Please complete the form as fully as possible – the immunisation programme has changed over the years, so amend as necessary.

Please note: It is the responsibility of the parent or guardian to keep a record of a child’s immunisation status.

Until we receive this information, your child may only be seen on an immediately necessary or emergency basis.

Immunisation Record

Immunisation Record

Please use this date format: DD/MM/YYYY.

Immunisations

Vaccine
Appox. age
Date Given

1st DTP, Hib and Polio (5-in-one)

2 months

PCV & Rotavirus

2 months

2nd DTP, Hib and Polio

3 months

1st Men C & Rotavirus

3 months

3rd DTP, Hib and Polio

4 months

2nd PCV & 2nd Men C

4 months

Hib & Men C booster

12-13 months

1st MMR & 3rd PCV

12-13 months

Pre-Sch. booster: DTaP, Polio & MMR

3 yrs & 4 mths+

HPV (girls only)

12 to 13 years

DT, Polio & Men C booster

13 to 18 years

Non-routine: BCG (Tuberculosis)

Birth

Non-routine: Hepatitis B

Birth

Overseas Registration

If you are from overseas and registering a child under 4 with the NHS for the first time, we need to know the exact vaccinations your child has received with dates (translated where necessary). For children over 4, if your child has received all the appropriate immunisations to date you may sign the disclaimer below:

I confirm that my child has received all infant immunisations up to and including the Pre-School Booster.

Parent/Guardian
Sending