Immunization Record Request Form

Patient Information

Contact Information

Patient Name

Give first and last names

Primary Phone

Use the format 317-555-1212

Date of Birth

Use the format MM/DD/YYYY

Alternate Phone

Use the format 317-555-1212

Parent / Guardian Name

Give first and last names

Email

Primary Care Physician

Preferred Office

Additional notes or questions

How would you like to receive your immunization copy?

Send to me via: EmailFax

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!

Secure Internet Services

Northpoint Pediatrics

Immunization Record Request Form

Notes About this Form

Locations

Community Health Pavilion on 146th

Community Hospital North Campus