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予防接種実施依頼申請書
healthseniors
This is a form issued by Toshima Ward for requesting the implementation of vaccinations for elderly residents. Applicants fill in details such as the recipient’s information, vaccination type, cost category, and reasons for not being able to receive the vaccine, and submit it to the ward health office. Eligible vaccines include pneumococcal, influenza, COVID‑19 (elderly), and shingles.
| What | 高齢者の予防接種実施を依頼する申請書 |
|---|---|
| Who | 被接種者（高齢者）とその家族・介護施設等の申請者 |
| When | 記載なし |
| Where | 〒171-0022 豊島区南池袋 2-1-1 豊島区保健所 保健予防課 予防接種グループ |
| How | 記入例に従い、必要事項を記入し、提出先へ郵送または持参 |
| Deadline | 記載なし |
| Contact | 記載なし |
Open the original PDF ↗ 2 pages
Source page: https://www.city.toshima.lg.jp/564/kenko/kenko/yobosesshu/1602151051.html
Checked 2026-11-01. 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.