Vaccination Access Pathway for Asplenic Patients
Referral and Prescription Form
<Referral Region>
	PATIENT DETAILS                         (optional fields*)	

*THCI	

Patient Name:    <PtName>	

Previous Name:   <Patient's previous name if Known>	

Medicare No:   <PtMCNo>	

DOB:   <PtDoB>		Gender: <PtSex>	

Address:   <PtAddress>	

Phone (h):   <PtPhoneH>	

Mobile:   <PtPhoneMob>	

Alternate Contact:   	

		Referrers Name:    <DrName>	

Provider No:    <DrProviderNo>	

Practice Address:   <DrAddress>	

Phone:  <DrPhone>    Fax:  <DrFax>	

Allergies	

<Reactions>	

	

Registration on the Spleen Australia Registry		  Yes		  No	
					
Planned splenectomy		  Yes			  No		Date: <Planned Splenectomy date if appropriate>	
					
Previous asplenia/hyposplenia related vaccines administered		  Yes		  No	

				Note: It is the Immunisation provider’s (i.e. GPs) responsibility to ensure 
there are no contraindications to each vaccine administration 
Please outline previous vaccination history (relating to asplenia)  
	
<Imm>

Other vaccinations not shown above: 	
	Vaccines to be prescribed and number of vaccines required:
Pneumococcal				Meningococcal				H.influenzae B			
											
Conjugate 13  (Prevenar 13)	1			Conjugate ACWY (e.g. Menectra)	1			Conjugate Hib (Hibrex)	1		
											
Polyvalent  23 (Pneumovax 23)	1				2						
											
				Recombinant B (Bexsero)	1						
											
					2						

Comments: 

Signed:		Date: <TodaysDate>	

ID Physician counter signature:		Date:	

Pharmacy Dispensing Date:		
	
	*Remember to countersign and date all individual vaccines.