Immunisation history

Request for details of immunisation history

Please use the form below to submit a request to the occupational health team for details of your immunisation history.

A charge of £10.00 will be made if a duplicate copy is required.

Details of immunisation history can only be requested if you are current staff or have left the Trust within the last six months.

Name

Assignment number

Date of birth

Address

Address 1

Address 2

City

Country

County

Postal Code

Email address

Position

Are you a new starter to the Trust? Required

Yes

Are you known by any other name?

I hereby give permission for information relating to my immunisation record which is held with Surrey and Sussex Healthcare NHS Trust occupational health to be released to the email stated on this form. Required

I accept

E-Signature

Date Required

Please bear in mind that you may be called in for an occupational health appointment subject to your current proof that is held on file.

I agree to the privacy policy

Immunisation history

Request for details of immunisation history

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