Request for revaccination advice from Public Health Services

Request for revaccination advice from Public Health Services
Were you, or a person you are contacting us about, a patient of Dodges Ferry Medical that received (or potentially received) a vaccine at this practice between July 2003 and 22 March 2023?*
As your response suggests that you or another individual have not received a vaccine at this practice, no further action is required. Thank you for your time.
Name of the person completing this form*

First NameLast Name
Date of birth*

DayMonthYear
Phone number*
Mobile Preferred
Email address
example@example.com
If you are completing this form on behalf of others, please list their full names and dates of birth here:
Are you (or anyone you are completing this form on behalf of) currently pregnant?
Do you (or anyone you are completing this form on behalf of) live with an infant (under 8 weeks old)?
Do you (or anyone you are completing this form on behalf of) have a weakened immune system due to either a medical condition or medication?
Do you (or anyone you are completing this form on behalf of) live with someone with a weakened immune system?
Do you have any particular concerns or questions you are hoping to receive advice on?

0/100
Privacy Statement

The personal information you provide to the Department of Health will be managed in accordance with the Public Health Act 1997 (Tas) and the Personal Information Protection Act 2004 (Tas)
- Your information will be used by the Department of Health to help support your health needs
- The Department of Health, Tasmania will not use or disclose the information for any other purpose (unless it is required by or authorised under law to do so).
By clicking Submit you indicate you have read the above statement and authorise the Department of Health to use and retain your personal information.
Please verify that you are human*
Should be Empty: