Immunization Record Request

Complete this form to send an immunization record request to the Midland County Department of Public Health.

Record requests will be reviewed during normal clinic hours (Monday-Friday 8am-5pm), and we will contact you to gather additional record release information.

If you have been immunized in the State of Michigan, you may be able to download your Immunization Record from the Michigan Care Improvement Registry (MCIR) by using the Michigan Immunization Portal.

If you are experiencing a medical emergency, call 911 or proceed to the nearest emergency room.

This form is secure and HIPAA-compliant. Please provide as much detail as possible.

1. Are you requesting an immunization record for a minor? *This question is required.

2. Provide requestor:

Name:
Relationship to minor:

2. Legal name of person you are requesting an immunization record for: *This question is required.

First Name
Last Name

3. Date of birth for the person you are requesting an immunization record for? (MM/DD/YYYY) This question requires a valid date format of MM/DD/YYYY.

calendar

4. How may we contact you to discuss release of information or any follow-up questions? *This question is required.

Phone
E-mail
Text

5. Contact information:

Phone number:
E-mail:
List other:

6. Is there anything else you would like us to know?