Authorization to Release Immunization Records

Authorization to Release Immunization Records
Who is requesting this release?*
Reason for Request?*
Which school grade/year are these records being requested for?*
Parent/Guardian Name*

First NameLast Name
Name of Organization*
Relationship to Patient*
Contact Number *
Patient Name (Please include full name)*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Warning - This Patient is over 18 and must submit this request.

By law, release of this record must be authorized by the patient.
Record to be released to:*
Due to security, this option is limited to postal mail, which can take up to two weeks. To expedite, we recommend having the record sent to the patient or parent/guardian via email and forwarding it to the third party.
Release method:*
Postal mail can take up to two weeks for delivery. To expedite, we recommend having the record sent via secure email.
Person/Organization
Contact Number
Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Email*

Confirmation Emailexample@example.com
Parent/Guardian Email*

Confirmation Emailexample@example.com
Signature

Clear
Age
Today's Date

MonthDayYear
Date
Should be Empty:

Warning - This Patient is over 18 and must submit this request.