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

*THCI	

Patient Name:    <<Patient Demographics:Full Name>>	

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

Medicare No:   <<Patient Demographics:Medicare Number>>	

DOB:   <<Patient Demographics:DOB>>		Gender: <<Patient Demographics:Sex>>	

Address:   <<Patient Demographics:Full Address>>	

Phone (h):   <<Patient Demographics:Phone (Home)>>	

Mobile:   <<Patient Demographics:Phone (Mobile)>>	

Alternate Contact:   	

		Referrers Name:    <<Doctor:Name>>	

Provider No:    <<Doctor:Provider Number>>	

Practice Address:   <<Doctor:Full Address>>	

Phone:  <<Doctor:Phone>>    Fax:  <<Doctor:Fax>>	

Allergies	

<<Clinical Details:Allergies/Adverse 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)  
	
<<Clinical Details:Immunisation List>>

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: <<Miscellaneous:Date (short)>>	

ID Physician counter signature:		Date:	

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