Find our 2025-26 Flu Vaccine Information HERE
 
Beginning Oct 1, we will be OPEN Monday - Saturday!  LEARN MORE
   
 NP PEDS MD is the advice app our nurses use. Find answers to kids' illnesses, behavior concerns, nutrition, wellness topics, medication charts, first aid, and more! If the app doesn't answer your question, send a NON-URGENT Request.

Immunization Record Request Form

Requests will be processed within 2 business days.

If Patient is 18 or older, they must complete this form with their own information and sign.
Add child(ren)'s name and date of birth below.
NameDate of Birth 
Give first and last name-If the Patient is 18 or older, they must complete this form with their own information.
No work emails; use personal/home email address only. If the Patient is 18 or older, they must complete this form with their own information.
Use the format 317-555-1212
Use the format 317-555-1212
Requests will be processed within 2 business days.
Additional notes or questions

LuxSci helps ensure HIPAA-compliance for email and web services.