Pitt County Forms Center

2. 
   
   

   Immunization Records Request

   
    Once the records are located, you will be contacted to arrange in-person pickup. Immunization records cannot be emailed or mailed. A signed records release form is required at pickup. You must bring a valid photo ID.

4. Patient Information
6. Full Name of Patient*
7. Date of Birth *
9. Any Previous Name(s) of Patient, if Applicable
11. Address *
13. Phone Number*
14. Email Address*
16. Relationship to Patient*

    Vaccine records can only be released to the patient or someone legally authorized to receive them. If you are requesting records for someone else, you may be asked to provide legal documentation showing your relationship to the patient.

    1. The record is for me
    2. Parent or legal guardian of a minor

    1. Legal guardian of an adult
    2. Authorized representative (power of attorney, etc.)
18. Requester Information If Different From Patient
20. Full Name of Requester Name
21. Date of Birth
23. Address
25. Phone Number
26. Email Address
28. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
30. Electronic Signature*
32. Date:
Leave This Blank:


34. Submit

* indicates a required field