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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.
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