← Yohaku ・ Tokyo ・ Nakano ・ 日本語
高齢者定期予防接種依頼書交付申請書
seniorshealthadmin
This is an application form to request the issuance of a vaccination request letter for regular elderly vaccinations (influenza or COVID-19) when unable to receive them in Nakano Ward due to hospitalization, nursing home admission, or long-term stay at a relative's home. It is intended only for those who wish to be vaccinated outside Tokyo's 23 wards or at medical institutions not contracted with the 23 wards.
| What | 高齢者定期予防接種（高齢者インフルエンザ、新型コロナウイルス感染症）の依頼書交付申請 |
|---|---|
| Who | 東京23区外および東京23区と契約していない医療機関で高齢者定期予防接種の接種を希望する方 |
| When | 記載なし |
| Where | 中野区（中野区長あて） |
| How | 申請書に申請者・被接種者の情報、中野区で接種を受けられない理由、希望する予防接種の種類、接種希望医療機関、依頼書送付先等を記入して申請する |
| Deadline | 記載なし |
| Contact | 記載なし |
Open the original PDF ↗ 1 pages
Source page: https://www.city.tokyo-nakano.lg.jp/kenko_hukushi/kenshin_yobousessyu/yobosessyu/otona-yobosessyu/koreisya-influenza.html
Checked 2026-09-15. 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.