This form is completed by the consenting parent and the lead maternity carer (LMC) after the birth immunisations.
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1 Instructions This form is completed by the consenting parent and the lead maternity carer (LMC) after the birth immunisations. The white LMC page is to remain with the maternity notes. Fax, or send a photocopy, of the white page to the DHB National Immunisation Register (NIR) Administrator (details overleaf). Send the yellow page to the Medical Officer of Health (details below). Send the green page to the patient s GP. Medical Officers of Health (send yellow page) Name Districts covered Address Phone Fax Northland District Health Board Northland Primary and Community Health Services PO Box 742 Whangarei 0140 Auckland Regional Public Health Service Toi Te Ora Public Health South Auckland Central Auckland North/West Auckland Waikato Ruapehu (northern part) Eastern Bay of Plenty Western Bay of Plenty Lakes (Rotorua/Taupo) Auckland Regional Public Health Service Private Bag Symonds St Auckland 1150 PO Box 505 Hamilton 3240 Toi Te Ora Public Health PO Box 2120 Tauranga 3140 Tairawhiti District Health Board Gisborne/Tairawhiti Te Puna Waiora Tairawhiti District Health Board PO Box 7001 Gisborne 4040 Taranaki District Health Board Taranaki Private Bag 2016 New Plymouth 4342 Hawkes Bay District Health Board MidCentral District Health Board Hutt Valley District Health Board Nelson Marlborough District Health Board Hawkes Bay Chatham Islands Manawatu Wanganui Ruapehu (southern part) Wellington Hutt Valley Wairarapa Nelson Marlborough Napier Health Centre PO Box 447 Napier 4140 Community Health Village Palmerston North Hospital PO Box Palmerston North 4442 Regional Public Health Hutt Hospital Private Bag Lower Hutt 5040 Nelson PO Box 647 Nelson 7040 Marlborough PO Box 46 Blenheim 7240 Community and Public Health Canterbury Community and Public Health PO Box 1475 Christchurch 8140 South Canterbury West Coast Community and Public Health PO Box 510 Timaru 7940 Community and Public Health PO Box 443 Greymouth 7840 Otago Private Bag 1921 Dunedin 9054 Southland Queenstown/Central PO Box 1601 Invercargill 9840 Frankton Queenstown 9349 (09) extn 7887 (09) (09) (09) (07) (07) (07) (06) (06) (06) (06) (06) (06) (06) (06) (04) (04) (03) (03) (03) (03) (03) (03) (03) (03) (03) (03) (03) (03) (03) (03) (03) (03)
2 DHB s (send white page) District Health Board Address Phone Fax Northland (09) Ext (09) Northland District Health Board PO Box 742 Whangarei 0140 Waitemata (09) (09) HealthWEST PO Box Lincoln North, Auckland 0654 Auckland Counties Manukau Waikato Bay of Plenty Lakes Tairawhiti Taranaki Hawkes Bay Whanganui MidCentral Hutt Valley Capital & Coast Wairarapa Nelson-Marlborough West Coast Canterbury South Canterbury Southern (Otago) Southern (Southland) HealthWEST PHO PO Box Lincoln North, Auckland 0654 Counties Manukau District Health Board Private Bag Otahuhu, Auckland 1640 PO Box 934 Hamilton 3240 National Immunisation Register Private Bag Tauranga 3143 Lakes District Health Board Pukeroa Hill Private Bag 3023 Rotorua 3046 Tairawhiti District Health Board Private Bag 7001 Gisborne 4040 David St Private Bag 2016 New Plymouth 4342 Hawkes Bay District Health Board Napier Health Centre PO Box 447 Napier 4140 Whanganui District Health Board Private Bag 3003 Wanganui 4540 MidCentral District Health Board Private Bag Palmerston North 4442 Regional Public Health Hutt Valley District Health Board Private Bag Lower Hutt 5040 Kenepuru Hospital Raiha St PO Box Porirua 5240 Wairarapa PHO PO Box 314 Masterton 5840 Nelson Marlborough District Health Board PO Box 647 Nelson 7040 West Coast District Health Board Community Services PO Box 387 Greymouth 7840 Canterbury District Health Board PO Box 800 Christchurch 8140 Primary Community Services South Canterbury District Health Board Private Bag 911, Timaru 7940 Southern District Health Board PO Box 5144, Dunedin 9058 Vaccine Preventable Disease Team Southern District Health Board PO Box 828, Invercargill 9840 (09) (09) (09) (07) (07) (07) (07) Toll free from Taupo and Turangi: (07) (07) (07) (06) Ext (06) (06) (06) (06) Ext (06) (06) (06) (06) (06) (04) (04) (04) (04) (04) (06) (06) (03) (03) (03) (03) (03) (03) (03) (03) (03) (03) (03)
3 Place of Birth: Alternative I consent / do not consent (delete which is not applicable) to the above child receiving the hepatitis B vaccine at birth. I consent / do not consent (delete which is not applicable) to this form being given to the Medical Officer of Health, the and the patient s GP to Protocols and record of vaccines given: Birth Hep B 5mcg HBIG 100 IU Key: Hep B = hepatitis B vaccine; HBIG = hepatitis B immunoglobulin; DTaP-IPV- = diphtheria, tetanus, Fax/post a copy of the white page to the DHB. Lead materinty carer
4 Place of Birth: Alternative I consent / do not consent (delete which is not applicable) to the above child receiving the hepatitis B vaccine at birth. I consent / do not consent (delete which is not applicable) to this form being given to the Medical Officer of Health, the and the patient s GP to Protocols and record of vaccines given: Birth Hep B 5mcg HBIG 100 IU Key: Hep B = hepatitis B vaccine; HBIG = hepatitis B immunoglobulin; DTaP-IPV- = diphtheria, tetanus, Fax/post a copy of the white page to the DHB. Medical Officer of Health
5 Place of Birth: Alternative I consent / do not consent (delete which is not applicable) to the above child receiving the hepatitis B vaccine at birth. I consent / do not consent (delete which is not applicable) to this form being given to the Medical Officer of Health, the and the patient s GP to Protocols and record of vaccines given: Birth Hep B 5mcg HBIG 100 IU Key: Hep B = hepatitis B vaccine; HBIG = hepatitis B immunoglobulin; DTaP-IPV- = diphtheria, tetanus, Fax/post a copy of the white page to the DHB. General Practitioner
Medical Officers of Health (send yellow page) Name Districts covered Address Phone Fax. Waikato District Health Board. Toi Te Ora Public Health
Instructions This form is completed by the consenting parent and the lead maternity carer (LMC) after the birth immunisations. The white LMC page is to remain with the maternity notes. Fax, or send a photocopy,
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