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An Official Pennsylvania Government Website

Department of Health

PIERS Immunization Record Update Request

Please complete this form if you tried to access your (or your child’s) immunization record through the PIERS Public Portal and your record was not found or you are requesting an update to your record.

Proof of Identification must be uploaded to complete your request.

Please allow up to 5 business days for processing your submission.

Is the request for you or on behalf of your child (under age 18)?

*

Is the request for you or on behalf of your child (under age 18)? SelfIs the request for you or on behalf of your child (under age 18)? Dependent

Name of person/minor whose information is being updated.

First Name

**

Last Name

**

Date of Birth (MM/DD/YYYY)

**

Gender

*

Current Street Address

**

City

**

State

*

ZIP Code

**

Current Email Address

***

Phone Number (XXX-XXX-XXXX)

**

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