ImmPact Immunization Record Request

The Maine Immunization Information System (ImmPact) is a statewide immunization information system that stores electronic immunization records. ImmPact combines the vaccines a person has received into a single record, even if they were given by different health care providers in the state.

Complete the following form to request your or your child’s ImmPact immunization record. Requests will be processed in the order they are received. Due to the high volume of requests, if you need a copy of your immunization record within the next 5 business days, please contact your health care provider.

A parent or legal guardian can request records for children under the age of 18 years. Individuals over the age of 18 years old must request their own record. You cannot request a record for your spouse/partner.

The Maine Immunization Program cannot provide a replacement CDC COVID-19 vaccine card. If you lost your COVID-19 vaccine card, you can request a copy of your immunization record, which includes the same information as the vaccine card, by completing the request form below.

Though most Maine health care providers participate in ImmPact, some do not regularly submit immunization information. Also, because ImmPact was started in 2002, vaccines given before that may not appear in your ImmPact record. View tips for finding old immunization records.

Patient Information
Relationship to Patient

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

Requestor Information
Requestor Address

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