SI(TIV)* 23vPPV N/A N/A N/A N/A PCV13 N/A N/A N/A N/A SI (QIV)* Quadrivalent Influenza Vaccine SI (TIV)* Trivalent Influenza Vaccine Practice No. (3): (Please provide a copy of the documentary proof for address of the practice, such as public utility bill or bank statement.) Name (in English): Name (in Chinese): Address (in English): Address (in Chinese): District: Telephone no.: Scheme(s)/Programme to this Application relates: HCVS VSS RVP PCD For application for enrolment in PCD only: Type of practice (Choose one for each place of practice): Non-governmental Organization Private University Service fee per vaccination# at the above practice: Eligible Pregnant Person Person aged Person with Person Person women aged 65 or 6 months to Intellectual Receiving /Vaccine above less than 12 Disability Disability old Allowance SI (QIV)* SI(TIV)* 23vPPV N/A N/A N/A N/A PCV13 N/A N/A N/A N/A SI (QIV)* Quadrivalent Influenza Vaccine SI (TIV)* Trivalent Influenza Vaccine
SI(TIV)* 23vPPV N/A N/A N/A N/A PCV13 N/A N/A N/A N/A SI (QIV)* Quadrivalent Influenza Vaccine SI (TIV)* Trivalent Influenza Vaccine Practice No. (3): (Please provide a copy of the documentary proof for address of the practice, such as public utility bill or bank statement.) Name (in English): Name (in Chinese): Address (in English): Address (in Chinese): District: Telephone no.: Scheme(s)/Programme to this Application relates: HCVS VSS RVP PCD For application for enrolment in PCD only: Type of practice (Choose one for each place of practice): Non-governmental Organization Private University Service fee per vaccination# at the above practice: Eligible Person /Vaccine Pregnant women Person aged 65 or above Person aged 6 months to less than 12 old Person with Intellectual Disability Person Receiving Disability Allowance SI (QIV)* SI(TIV)* 23vPPV N/A N/A N/A N/A PCV13 N/A N/A N/A N/A SI (QIV)* Quadrivalent Influenza Vaccine SI (TIV)* Trivalent Influenza Vaccine
DH_eHS(S)002_(09-17)_Eng.docx