Immunization Record Request Form

Patient Information



Give first and last names



Use the format MM/DD/YYYY



Give first and last names



For directions to each of our locations, please see our Location pages.


Contact Information



Use the format 317-555-1212



Use the format 317-555-1212



Yes No

Additional notes or questions


Limit: 1,500 Characters

How would you like to receive your immunization copy?


Email
Fax



Note: Some work email accounts will not allow secure messages past their firewall – such as Lilly and Roche. For this reason, please provide a home or personal email address rather than work email.



Please enter in the word you see

   




Notes About this Form

Other Types of Medical Record Requests

We cannot release any other medical records via email without having a release of records completed by you the parent first.  Print the form, complete it and email to us and we will process your request.  For example:

  • copies of the chart
  • labs
  • referral letters

To release vaccine records directly to a third party, such as a daycare or school, the parent must complete a release of records.  Once receiving a vaccine record from us, many of our parents forward vaccine records to the daycare or school themselves and then have an email trail!

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