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Counseling and Wellness Office Immunization Record Request Form

month/day/year
Please type your full name.
  • Please allow 1-2 weeks from the date this request is received for records to be sent.  
  • Records are kept on file for 7 years.  If your record is not available for any reason, someone will contact you.  
  • If your immunization records are not available, it is recommended that you contact the medical facility where you received the immunizations.
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