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

Immunization Records Request Form


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


City, State, Zip

Phone Number

Primary Office *REQUIRED

Form Receipt

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

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

(Answering this tells the system you aren't a spam robot)

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