Get Immunization Record Request English.doc. Application For Guest Tattoo Artist Registration

Filling out the Immunization Record Request is an essential step in obtaining necessary immunization records for various purposes. This guide provides you with clear, step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out your immunization record request form.

1. Press the ‘Get Form’ button to access the document and open it in your preferred editor.
2. Indicate the reason for the request by checking one of the two options: 'Record needed for Social Security Application' or 'Record needed for daycare/school'.
3. Fill in today’s date and the time of the request in the designated fields.
4. Provide the patient’s full name by entering their last name, first name, and middle name in the appropriate fields.
5. List any other names the patient has used on the line provided to ensure all records can be retrieved.
6. Enter the patient's age and date of birth accurately to help confirm their identity.
7. Record the patient’s social security number as it may be required for processing the request.
8. Fill out the current address fields, including street address, city, state, and ZIP code.
9. Indicate whether the patient attends Putnam County School by selecting yes or no.
10. If applicable, provide the name of the school and the grade the patient is in.
11. Provide a home phone number and an alternative contact number for follow-up, if necessary.
12. Answer the question regarding whether the patient has ever had chicken pox by selecting yes or no. If yes, provide the age at which they had the illness.
13. If the patient is a minor, include the parent’s name in the designated area.
14. Once all information is filled out accurately, you can save changes, download, print, or share the completed form as needed.

Complete your immunization record request form online today to ensure you have the necessary documentation!