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2. Immunization requests can only be submitted online - please do not walk in to the health center to make a request. This allows us to take the time needed to get you the most accurate and thorough information.

4. First Name*
5. Middle Name
6. Last Name*
8. Other Names/Also Known As
10. Date of Birth*
    Date of Birth
12. Address*
13. City*
15. State*
16. Zip Code*
17. County*
21. Name of Person Requesting Record*
22. Relationship to Client*
24. Phone Number*
26. How to Receive Record*

    1. I would like to pick up the record at Clay County Public Health Center. Please contact me by phone when it is ready.
    2. Fax the record to the number below.
    3. Mail the record to the address above.
    4. Email the record to the address below.
28. Which records would you like?*

    1. I only want the COVID immunization record (will include lot # and clinic where vaccine was administered)
    2. I would like the entire immunization record
30. Name of Person/Facility Receiving Record*

    Persons or facilities who can receive immunization records: Parent or Legal Guardian, Schools/Group Homes/Medical Facilities, Foster Parents, or Legal Guardian of an Incapacitated/Disabled Adult.

    A parent cannot request records for a child 18 and older.

31. Email Address
32. Fax Number
34. Additional Notes
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field