Camillus: (315) 487-1541
Liverpool: (315) 652-1070

Immunization Records Request Form

Instructions

Please be sure to complete this entire form to ensure proper processing of your request, then click on the Submit button.

Please fill out completely

Patient Information

Patient's Name (required)

Patient's Birthdate

Parent's Name

Address

City, State, Zip

Phone Number

Primary Office *REQUIRED
 Camillus Clay/Liverpool

Form Receipt

Where would you like us to send this immunization record?
 Mail to my home Fax to:

  • Home - Fax: Attn:
  • Work - Fax: Attn:

(Answering this tells the system you aren't a spam robot)
1+1=? 

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