Masks are optional but highly advised with all patients with respiratory symptoms. Masking with continue to be required for our Sat/Sun walk in clinics .
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Immunization Record Request Form

Patient Information
Contact Information
Give first and last names
Use the format 317-555-1212
Use the format MM/DD/YYYY
Use the format 317-555-1212
Give first and last names
Additional notes or questions
How would you like to receive your immunization copy?

Notes About this Form

Other Types of Medical Record Requests Need a Release of Records Form Completed

+Release of Records

Print the form, complete it and email to us and we will process your request.  For example copies of the chart, labs and 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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