Immunization Records Request

You may request a copy of your child(ren)'s immunization records by completing the information below.



Guardian Information





Telephone number(s) you can be reached at during the day.

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Patient Information

Send immunization records for the following patient:






Delivery Method


If by mail:

If by fax:

 
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Authorization


Electronic Signature

By entering my name below, I understand that I am providing an electronic signature which will serve as an affirmation that I'm the parent/legal guardian of the patient entered above.:





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