Vaccine Record Request

Tarrytown Pharmacy Vaccine Record Request

Thank you for entrusting Tarrytown Pharmacy with your immunization needs! Please fill out this form if you would like us to email you a copy of your vaccination records.
Name of Patient*

First NameLast Name
Date Of Birth*

MonthDayYear
Date
Email - Record will be sent to this email (please double check for accuracy)*
example@example.com
Please select from the following:*

I am requesting a copy of ALL immunizations received from Tarrytown PharmacyI am requesting a specific vaccine record
Specific Vaccine You Need a Record Of (include name of vaccine and estimated date)
Where did you receive your vaccines?
Name of Company/Where Clinic was Located
If you need us to fax your records to your doctor's office or elsewhere, please include their full name and fax number below.
Consent For Medical Record
Name of Person Requesting Health Record *

First NameLast Name
Relationship to Patient*

SelfParent/GuardianOther
Authorization for Release of Information:

I hereby authorize Tarrytown Pharmacy to release my immunization records to the email address provided above. I understand that this authorization is voluntary.

Purpose of Request:

I am requesting a copy of my immunization records for personal use.

Terms of Consent:
- I understand that the information disclosed may include details about my immunizations, which are part of my confidential medical records.
- I acknowledge that email communication is not entirely secure and may be intercepted by unauthorized parties. Despite this, I consent to receiving my immunization records via the email address I have provided.
- I understand that once my immunization records are disclosed pursuant to this authorization, they may be subject to re-disclosure by the recipient and may no longer be protected by privacy laws.
Acknowledgement*

By signing below, I acknowledge that I have read and understand the terms of this authorization and consent to the release of my immunization records as specified above.
Signature*

Clear
Date Signed*

MonthDayYear
Date
Should be Empty:

Tarrytown Pharmacy Vaccine Record Request

Consent For Medical Record