web

You’re offline. This is a read only version of the page.

Skip to main content

An Official Pennsylvania Government Website

Department of Health

Authorization For Release Of Immunization Records

Introduction:

I hereby authorize the Pennsylvania Department of Health to release information/records in its Pennsylvania Immunization Electronic Registry System (PIERS) files relating to immunizations received by:

Name of person/minor whose information is being released:

First Name

*

Last Name

*

Birth Date (MM/DD/YYYY)

*

Address

*

City

*

State

Zip Code

*

Phone Number (XXX-XXX-XXXX)

**

Email

**

I authorize the information/records to be sent to:

Name

*

Address

*

Email

**

Phone Number (XXX-XXX-XXXX)

**

ACCESSIBILITY
PRIVACY & DISCLAIMERS
TRANSLATION DISCLAIMER
SECURITIES