Fields marked with an * are required Vaccine Record Request Please fill out the following information so we can obtain your record for you. I am submitting this request for: * Myself Minor Child (17 years and younger) Legal First Name * First Legal Last Name * Last Date of Birth * MM/DD/YYYY Phone Number * Email Fax Number Street Address * Address Line 2 City * State * Zip Code * How do you want this record sent? (Please make sure the information above is filled in appropriately.) * Email Mail (USPS) In Person Pickup Fax reCAPTCHA If you are human, leave this field blank.
