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IMMUNIZATION RECORD REQUEST

NORTH DAKOTA DEPARTMENT OF HEALTH

SFN 58454 (11-09)

Please complete this form in its entirety. Contact the North Dakota Department of Health (NDDOH) Immunization Program at 701.328.3386 or 800.472.2180 if you have questions. Return this form to: N.D. Department of Health Division of Disease Control Attn: Immunization Program 2635 East Main Ave PO Box 5520 Bismarck, ND 58506-5520 or 701.328.2499

Fax this form to:

PLEASE PRINT

Date of request: Name of record requested: Street address: Telephone number: Date of birth: What method would you like this information sent? (Please Check): Fax Mail Address of where immunization record should be sent (if different from above): City: State: Zip Code: City: State: Zip Code:

Fax number where immunization record should be sent: Name of individual or personal representative of record requested: Relationship to person whose record has been requested: Signature of individual or personal representative: Date:

Self

Parent

Guardian

Note: This form will be kept on file at the NDDoH for one year from date of request.

Information

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