http://www.scribd.

com/doc/100579829/Web-Appc-PentestiNHVPR-F-3 v5 February 2013 To return this form FAX: (03) 8360 8699 or MAIL: Reply Paid 725, Sunshine VIC 3020 For assistance or enquiries please call 1800 478 734 (1800 HPV REG) or visit www.hpvregister.org.au CONSUMER/PATIENT DETAILS SCHOOL DETAILS Surname: School Name: First Name: Middle Name(s): School Postcode: Year Level: CONSENTER DETAILS Previous Surname (if applicable): Consenter Name (if applicable): Date of Birth: // Gender: Female Male Relationship to Consumer: Medicare Number: Person Number on Card: Consenter Address: (tick if same as consumers address) Is the consumer of Aboriginal or Torres Strait Islander origin? Suburb: State: No Aboriginal Torres Strait Islander Both Aboriginal and Torres Strait Islander Postcode: Consenter Contact Number: Address: Suburb: State: Postcode: Phone Number: Postal Address (if applicable): VACCINATION DETAILS Vaccine Brand:are given in general practice or other healthcare settings (eg. absence from school, personal preference). Why notify? Notifying the HPV Register helps providers and patients to ensure HPV vaccine courses are completed. The HPV Register can help by: sending completion statements to those who have received all 3 vaccinations sending history statement reminders to those with an incomplete course within the schools program providing online overdue dose reports to providers, listing patients who have incomplete courses enabling providers to check the vaccination stacan notify HPV vaccine doses. Medical practitioners can set up access to their online account for practice managers and nurses, to facilitate submission of notifications within the practice. Patients can opt-off at any time by contacting the HPV Register. NHVPR-F-3 v5 February 2013 How can I notify? Methods for notifying HPV vaccine doses Online HPV Register Secure Site Document -based faxed or posted to the HPV Register Single Dose

 HPV Vaccination Notification form Multiple Doses HPV Vaccination Notification form template (multiple doses) Reports generated from practice software Requirements for notification Consumer consent (written or verbal) Minimum fields completed: > Patient - Name, DOB, Gender, Address, Medicare Number > Vaccination - Date, Dose Number, Vaccine Brand > Practitioner - Provider Number Note: Entering HPV vaccination details into practice software does not automatically result in notification to the HPV Register. The online portal, forms and templates are all accessible at hpvregister.org.au/health-professionals Where can I get more information? National HPV Vaccination Program Register www.hpvregister.org.au Tel: 1800 478 734 Fax: 03 8360 8699 Posted notifications: Reply Paid 725, Sunshine Vic 3020 Immunise Australia www.immunise.health.gov.au 1800 671 811 Australian Medicare Local Alliance www.amlalliance.com.au Tel: 02 6228 0800 hpv vaccination notificatio N Has your practice notified HPV vaccinations to the Register?ng-02-2011#download