Immunization request form 2026

1. Click ‘Get Form’ to open the immunization request form in our editor.
2. Begin by filling out the 'Individual or Child Information' section. Enter the full name, date of birth, and mother's maiden name for identification purposes.
3. Provide the gender and phone number. Ensure that your street address, city, state, and ZIP code are accurately filled in.
4. If you are 18 years or older, sign and date the form. If you are a parent or guardian completing this on behalf of a minor, fill in your details in the designated section.
5. Include a photocopy of your driver’s license or state-issued ID with sensitive information shielded. Attach a self-addressed stamped envelope for returning your records.
6. Review all entries for accuracy before submitting. Once completed, return the form to the Massachusetts Department of Public Health as instructed.

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