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定期予防接種予診票交付申請書（ご本人様申請用）
healthchildrenseniors
This is an application form to request the issuance or reissuance of vaccination screening questionnaires in Minato Ward by mail. It is used when questionnaires are lost, damaged, after moving in, or if vaccination was previously missed due to poor health, covering various routine vaccines for children, adults, and seniors. If requesting delivery to an address other than the registered address, copies of identity verification documents for both the vaccine recipient and applicant are required.
| What | 予防接種予診票等の交付・再交付申請 |
|---|---|
| Who | 港区に住民登録があり、定期予防接種の予診票等の交付を希望する本人または代理人 |
| When | 記載なし（インフルエンザは9月24日～翌年1月31日まで、新型コロナウイルスは10月1日～翌年3月31日まで等の記載あり） |
| Where | 区指定の医療機関でのみ使用可能（送付先は現住所またはその他指定住所） |
| How | 申請書に必要事項（被接種者情報、申請者情報、発行理由、希望する予防接種の種類、送付先等）を記入し郵送等で申請（現住所以外への送付希望時は本人確認書類の写しが必要） |
| Deadline | 記載なし |
| Contact | 記載なし |
Open the original PDF ↗ 1 pages
Source page: https://www.city.minato.tokyo.jp/hokenyobou/kenko/kenko/yobosesshu/influ.html
Checked 2026-09-12. This page restates the PDF in a fixed structure; nothing is added or removed. Where the PDF does not say, the field reads "not stated". The original Japanese PDF is authoritative — confirm dates and conditions there.