Occupational Health Service

Health Work and Well Being Centre

Longmoor Lane

Liverpool

L9 7AL

Date: …………………………

REQUEST FOR COPY OF IMMUNISATION RECORD

I, the undersigned, give my consent for the Occupational Health Department at Aintree University Hospitals NHS Foundation Trust to release my immunisation details to the following person / organisation.

PLEASE PRINT IN BLOCK CAPITALS

Name: / Date of birth:
Previous Names: / Signature:
E-mail address:
I will collect this from the Health Work and Well-being Centre. Please ring me when
this is ready for collection
telephone number______
Please send this out in the post to me / my new Occupational Health Department.
Home Address / Name & Full address of OH Department information to be sent to:
Fax no:

Please be aware that if we have already sent you an Immunisation Record and there have been no changes since, this will be considered a duplicate report and you will be charged £10

Please send this form to:

Health Work and Well-being Centre

Aintree University Hospitals NHS Foundation Trust

Longmoor Lane

Liverpool

L9 7AL

Alternatively fax the completed form to 0151 529 3598 or scan and e-mail to