Texas Immunization Record Request Form

Full Name of Person on Record

First NameLast Name

Date of Birth

Date

Your Relationship to Person on Record

Other

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Current Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Reason for Request

Other

Preferred Delivery Method

Additional Notes or Special Instructions

Signature (Authorization for Release)