Immunization Record Copy Request Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

If you've lost your vaccination card for your COVID-19 shot, we cannot issue a replacement but we can print a copy of your immunization record. We will need to see a copy of your government issued ID (drivers license, passport, etc)

First and Last Name

Full Address

Date of Birth

YYYY

Phone Number

We will contact you via phone when your records are ready to be picked up. Please bring your government ID with you to pick them up.

The address on your medical record and your ID must match.

Unable to make it into the office during business hours to pick up your records? Please check this box and we will contact with you with additional information.

Yes

Requesting identification, such as a state-issued ID (such as Driver’s License), is appropriate as Iowa state law [Iowa Code § 22.7(2) and 641 IAC Chapter 7] specifies immunization information is confidential, and can only be shared with the individuals themselves or their parent/guardian if the person is a minor.

The Iowa Immunization Program encourages all providers to secure COVID-19 Vaccination Cards in their possession to avoid misuse. Unauthorized use and reproduction of the cards constitute fraud and are subject to criminal or civil prosecution for violation of 18 U.S.C. § 1001, 42 U.S.C. § 1320b-10, or other relevant federal statutes.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms