General Practitioner Template
Immunisation Register (IM011.1609)
A professional General Practitioner template for healthcare professionals.
About this template
Used by general practitioners and authorised health professionals to notify the Department of Human Services when an individual has a valid medical contraindication or natural immunity that exempts them from vaccination. It records the reason for exemption, applicable vaccines, and evidence such as clinical diagnosis or laboratory results. Heidi automatically pre-fills the patient’s details and relevant clinical information from the consultation, helping clinicians complete accurate exemption notifications quickly and in compliance with national immunisation requirements.
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Immunisation Register
**Patient Details**
* **Patient Name:** John Smith
* **Date of Birth:** 12/03/1965
* **NHS Number:** 123 456 7890
**Immunisation History**
| Vaccine Name | Date Administered | Batch Number | Site of Injection | Administering Clinician | Adverse Reactions | Next Due Date |
| :----------------------- | :---------------- | :----------- | :---------------- | :---------------------- | :---------------- | :------------ |
| Influenza (Flu) | 01/11/2024 | ABC123 | Left Arm | Dr. Thomas Kelly | None | Annually |
| Pneumococcal (Pneumo) | 15/09/2023 | DEF456 | Right Arm | Dr. Thomas Kelly | Mild soreness | 5 years |
| Tetanus, Diphtheria, Polio | 20/07/2022 | GHI789 | Left Arm | Dr. Thomas Kelly | None | 10 years |
**Notes**
* Patient informed of potential side effects.
* Vaccine information leaflet provided.
* Patient advised to seek medical attention if adverse reactions persist.
**Clinician Signature:** Dr. Thomas Kelly
**Date:** 01/11/2024
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Specialty
General Practitioner
Used
4 times
Type
Form Template
Last edited
11/13/2025
Created by
Lachlan Reid