*Lost Vaccine Card - Request for Vaccine Documentation

Request for COVID-19 Vaccine Documentation - Lost Vaccine Card
Please use this form to request your COVID-19 Vaccination Documentation.

New vaccine cards may be picked up at Centennial Pharmacy Services at:

1020 N Delaware Avenue, Philadelphia PA, 19125

Monday - Friday from 9:00 AM - 5:00 PM

If you choose to pick up your card, it is free of charge.

If you are requesting your vaccine card to be mailed to you, please note there is a $5 service fee.

Your card will be ready for pick up or mailed 2 business days after this form is submitted. Thank you!
Name

First Name Last Name
Date of Birth

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Additional Information
Please feel free to provide the location, date of your vaccination (if known), or any other information.
Pick up or Mail
Mailing Service Fee

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USD Mailing Service Fee
Should be Empty:

Request for COVID-19 Vaccine Documentation - Lost Vaccine Card