Attachment C: Change of Details Form (Model Form) (a) Practice Details Name of Practice Address (b) Changes to Practice Details New Practice Name: □ Change of Practice Name New Practice Address: □ Change of Practice Address New Telephone number: □ Change of Telephone number New Email: □ Change of Email Change of Contact for New Contact Person: Administrative Requirements relating to Yellow Fever Vaccination □ (practice manager or other) □ Other (d) Changes to Practitioners who are prescribing the yellow fever vaccine ADD REMOVE 1 Name: □ □ AHPRA Number: □ Course completion certificate attached: 2 Name: □ □ AHPRA Number: □ Course completion certificate attached: 3 Name: □ □ AHPRA Number: □ Course completion certificate attached: 4 Name: □ □ AHPRA Number: □ Course completion certificate attached:
Attachment C: Change of Details Form (Model Form) (a) Practice Details Name of Practice Address (b) Changes to Practice Details Change of Practice Name □ New Practice Name: Change of Practice Address □ New Practice Address: Change of Telephone number □ New Telephone number: Change of Email □ New Email: Change of Contact for Administrative Requirements relating to Yellow Fever Vaccination (practice manager or other) □ New Contact Person: Other □ (d) Changes to Practitioners who are prescribing the yellow fever vaccine ADD REMOVE 1 Name: AHPRA Number: Course completion certificate attached: □ □ □ 2 Name: AHPRA Number: Course completion certificate attached: □ □ □ 3 Name: AHPRA Number: Course completion certificate attached: □ □ □ 4 Name: AHPRA Number: Course completion certificate attached: □ □ □
wGuidelines-Yellow-Fever-Vaccination-Centres.docx