CIIS Record Request

CIIS Record Request

Please complete this form to request your CIIS immunization record. (Form found at: https://www.larimer.gov/health/communicable-disease/coronavirus-covid-19/covid-19-vaccine)
Form link found at: https://www.larimer.gov/health/communicable-disease/coronavirus-covid-19/covid-19-vaccine
Please note:

You may only request your own record or the record(s) of your minor children.

This record would include any immunizations provided by a healthcare provider in Colorado, including COVID vaccines. Immunizations provided by federal healthcare providers (such as the Veteran's Administration or the military) and providers outside of Colorado may not be included in the record unless they have been entered as a historical record.
This request is for:*

My own CIIS recordMy child's CIIS record
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a resident of Colorado?

YesNo
How would you like to receive your immunization record?

Encrypted email (PDF attachment)MailPick up in Fort Collins
Should be Empty: