Immunization Record Request Form

Patient Information

Patient's Name *

Give first and last names

Date of Birth *

Use the format MM/DD/YYYY

Parent or Guardian's Name *

Give first and last names

Preferred Office

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

Primary Care Physician

Contact Information

Primary Phone *

Use the format 317-555-1212

Alternate Phone

Use the format 317-555-1212

Email *

Would you like to subscribe to our Mailing List?
Yes No

Additional notes or questions

Limit: 1,500 Characters

How would you like to receive your immunization copy?

Send to me via:
Email
Fax

Email

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.

Fax

Please enter in the word you see

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