PCHD Vaccine Record Request

VACCINE RECORD REQUEST
To request a copy of a vaccine record, please fill out the information below. People or facilities who can receive immunization records: Parent or Legal Guardians/Custodians, Schools, Group Homes, or Medical Facilities.

Note: A parent cannot request records for a child 18 and older.

Requests may take up to 2-4 business days to process.
CLIENT INFORMATION
Name*

First NameLast Name
Other Names/Also Known As
Date of Birth*

MonthDayYear
Date
Address*
City*
State*
Zip/Postal Code*
REQUESTOR INFORMATION
Name of Person Requesting Record*
Relationship to Client*
Phone Number*
Please enter a valid phone number.
HOW WOULD YOU LIKE TO RECEIVE THE RECORD?
Please select how you would like to receive the record:*

I would like to pick up the record at Platte County Health Department. Please contact me by phone when it is ready.Fax the record to the number below.Mail the record to the address above.Email the record to the address below.
Name of Person/Facility Receiving Record*
Email Address/Fax Number
AUTHORIZATION
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

VACCINE RECORD REQUEST