COVID-19 Vaccine Card Replacement Form

COVID-19 Vaccine Card Replacement Form
This form is to request a NEW physicial COVID-19 Vaccine Replacment Card. The replacement card will require a service fee of $5 dollar which is Non-refundable. Your record of reception of the COVID-19 Vaccine MUST have been uploaded on the state website if you didn't get the vaccine from us.

If you are just looking for your vaccine record, then you may request it directly from the Department of Health in one of the two ways for FREE :
1. ONLINE: Request your immunization record.
2. BY MAIL OR EMAIL: Fill out this form and mail or email it in.
You will need to upload or send in a copy of your photo ID to access your records.
Contact Information
Name *

First Name Last Name
Date of Birth *

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

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Replacement Reason *
Upload a phot copy of your Vaccination Card if you have it.

Cancel of
Because of the reasons stated above, I, the undersigned, request that my CDC COVID-19 Vaccine card be changed. I acknowledge that the relevant health information contained on the replacement card belongs to me and that I received the dose(s) indicated on the card. I promise that I will not use this replacement card for any purpose other than to provide confirmation of immunization receipt.

I agree the payment of The vaccine replacement card is non-refundable once submited.
Date *

Month Day Year
Date
Signature *

Clear

My Products *

COVID-19 Vaccine Replacement Card Service Fee This is a Non-Refundable Payment for COVID-19 Vaccine Card.

$ 5.00

Total

$ 0.00

Credit Card

Should be Empty:

COVID-19 Vaccine Card Replacement Form

Contact Information

Credit Card