Shot Record Request Form - Toledo Lucas County Health Department printable pdf download

Shot Record Request Form - Toledo Lucas County Health Department

NEWBORN up to 17 YEARS OLD

Shot Record Request Form

Toledo Lucas County Health Department

635 N. Erie St. Toledo, Ohio 43604

FAX: 419-213-4196

The Toledo-Lucas County Health Department maintains the records of patients that have been seen at one of

our clinics. We do not have the patient records of physicians that have retired or closed their practices. Many

physicians participate in the Ohio Immunization Registry, but it is not mandatory and use by physicians

increased around the mid 1990’s. Although all ages are included in the Registry, it is more likely to contain

complete immunization records for children than adults.

Today’s Date: _______________

Name (patient):____________________________________/____________

(First Name)

(Middle Initial)

__________________________________________________________________________________

(Last Name – Including Maiden Name)

Date of birth (patient):__________/__________/__________

(Month)

(Date)

(Year)

Phone Number: (_____)________________________________

Do you need this shot record for social security?

Yes

Can we leave a message at this phone number for you?

Yes

Has this person ever been to Shots for Tots n Teens?

Yes

Name of Parent/Guardian:______________________________________________

(First, Middle, and Last Name)

Current Mailing Address: ______________________________________________

(Address – please include Apartment #)

___________________________________________________________________

(City, State, and Zip Code)

Parent or Guardian Signature:_________________________________________

Please return this completed form to the address or fax number above. Records may be picked up on a

walk-in basis at the Health Department during business hours. Requests for Shot Records will be processed as

quickly as possible, but may require up to 72 hours to process.

All records will be mailed to the address shown above unless requested otherwise.

The Toledo-Lucas County Health Department is an equal opportunity provider.

Date Completed ________________________

Completed By _______________________

Shot Record Request Form - Toledo Lucas County Health Department