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Vaccine Record Request Form
Fill out your details to request your vaccine records.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Person Requesting Records
*
First Name
Last Name
Relationship to patient
*
Phone Number
*
Please enter a valid phone number in case we need to call with questions.
Format: (000) 000-0000.
If patient has ever had a different last name(s), list name(s) below
If the patient has received vaccines in another state, list the state(s) below
I authorize Super Shot to communicate with me electronically through e-mail. I understand that this e-mail communication is not secured by encryption therefore is not considered a secured or private communication. Super Shot will not be held responsible for further disclosure of your information sent via unencrypted e-mail.
*
I understand
Email address you want records sent to
*
example@example.com
If you'd like the records sent to a 2nd email address, please provide here:
example@example.com
I declare under the penalty of perjury under the laws of the State of Indiana that the foregoing is true and correct. I understand that the immunization record to be disclosed will be disclosed in accordance with this authorization and within Indiana Code 16-38-5-3. I am authorized to view this record as an individual or as the guardian of the record I am requesting.
I agree to the aforementioned patient confidentiality statement
Signature
Request Records
Request Records
Should be Empty: