COVID-19 Vaccine Card Replacement Form

COVID-19 Vaccine Card Replacement Form
Contact Information
Name
First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Replacement Reason
Because of the reasons stated above, I, the undersigned, request that my CDC COVID-19 Vaccine card be changed.
I acknowledge that the relevant health information contained on the replacement card belongs to me and that I received the dose(s) indicated on the card.
I promise that I will not use this replacement card for any purpose other than to provide confirmation of immunization receipt.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty:

Contact Information