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Click ‘Get Form’ to open the Immunization Record Request in the editor.
Enter today’s date in the designated field at the top of the form.
Indicate the number of copies or originals you are requesting by checking the appropriate box and entering the quantity.
Fill in your name, phone numbers (home, cell, work), fax number, email address, and mailing address in the required information section.
For each patient record requested, provide their last name, first name, and date of birth in the specified fields. Repeat this for each patient as needed.
Once completed, save your document and choose to fax it directly using our platform to (719) 578-3192 or mail it to the provided address.

Start filling out your Immunization Record Request today for free using our platform!

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Versions	Form popularity	Fillable & printable
2014	4.1 Satisfied (22 Votes)
2011	4 Satisfied (38 Votes)

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