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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?


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 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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