DHHS → ImmPact Immunization Record Request

ImmPact Immunization Record Request

Patient Information

First Name

Middle Name

Last Name

Date of birth

Gender

Phone

Relationship to Patient

Self

Parent/Guardian

Note that if you choose Parent/Guardian, you MUST provide your first and last name.

First name (if patient is a minor)

Last name (if patient is a minor)

Requestor Information

Name

Address

City/Town

State

ZIP/Postal Code

I understand that email and the internet have risks that the office sharing my information cannot control. It is possible that my emailed information could be read by a third party. I ACCEPT THOSE RISKS and still ask to send my information by email.

Electronic Signature

By checking this box and by entering your full name below, that you certify under penalty of perjury that you are the Patient or Parent/Guardian of the minor patient and are therefore authorized to access the patients ImmPact immunization record.

Full name

Date