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Step 1: Enter Your Information
Requestor First Name:
Requestor Last Name:
Patient
Date of Birth:
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Requestor Email Address:
Requestor Confirm Email:
Please keep my email address for future vaccine reminders from the Indiana State Department of Health
Step 2: Enter Security Info & Agree
PIN #:
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By clicking this box I agree to patient confidentiality and I declare under the penalty of perjury under the laws of the State of Indiana that the foregoing is true and correct. I understand that the immunization record to be disclosed will be disclosed in accordance with this authorization and within Indiana Code 16-38-5-3. I am authorized to view this record as an individual or as the guardian of the record I am requesting.