Nurse Practitioner Clinics Australia (NPCA) is registered as a recognised vaccination provider by the Department of Health and Australian Immunisation Register (AIR). If you’d like us to update your AIR/Dept. of Health medical record with the vaccination we give you please complete the following form. Please note that NPCA will only use this information to upload your AIR record and will NEVER use this data for any other reason.

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AIR Registration

id

date_time

First Name

Last Name

Email

DOB

Gender

Please Select Male Female Other

Home Address

Medicare Card Number

Medicare Individual Reference Number (alongside your name)

Suburb

State

Postcode

Street

Vaccination Details

Company Name

Vaccination Location

Date of Vaccination

Submit