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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
Please select an option
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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)