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高齢者インフルエンザ予防接種予診票交付・再交付申請書
healthseniors
This is an application form to request the issuance or reissuance of pre-vaccination screening questionnaires for elderly influenza and COVID-19 vaccinations in Nakano Ward. It is used when a questionnaire is needed due to moving into the ward or loss, and provides options for pick-up at the counter or delivery by mail.
| What | 高齢者インフルエンザ予防接種および新型コロナウイルス感染症予防接種予診票の交付・再交付申請 |
|---|---|
| Who | 被接種者本人、家族等 |
| When | 記載なし |
| Where | 窓口または郵送（具体的な窓口場所の記載なし） |
| How | 申請書に申請者情報、被接種者情報、希望する予防接種の種類（高齢者インフルエンザ／新型コロナウイルス感染症）、送付先、申請理由を記入して提出 |
| 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 2026-09-14. 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.