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(319) 385-0779

Immunization Record Request

To request an immunization record, please fill out the form below and we will get back to you as soon as we can. Thank you.

First and Last Name
mm-dd-yyyy
Email
Phone number

By submitting this form, I certify that the information provided is accurate and that I am the person named on the form or the parent or legal guardian of the minor named on the form. I request that Henry County Public Health provide the immunization record to the email address I provided.