Arizona Department Of Health Services - Immunization Record Request Form

In order to streamline support requests and better serve you, we utilize a support ticket system. Every support request is assigned a unique ticket number which you can use to track the progress and responses online. For your reference we provide complete archives and history of all your support requests. A valid email address is required to submit a request.

All immunization record requests must be accompanied by documents that identify the person requesting the immunization record. Examples of acceptable forms of identification are a state-issued photo driver's license with address, a state-issued photo identification card with address or a U.S. passport or passport card with photo. Please lighten the copy of the identification cards.

If the record requested is for a minor under 18 years of age, please state your relationship to the minor in the "Requestor's Relationship" field.

Immunization record requests will be processed within 5-7 business days.
*Due to an increase in immunization records requests, please anticipate delays.

Request Info

Who are you requesting this for? *

What immunization records are you requesting? *

All immunizations, including COVID-19

All immunizations on file with the Arizona Department of Health Services (excluding COVID certificate)

COVID-19 Only

Personal Info

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *
Male Female

Phone Number *

Country *

Current Address *

City *

Province/State *

Postal Code *

Requester Info

If the record requested is for a minor under 18 years of age, please state your relationship to the minor in the "Requestor's Relationship" field.

First Name *

Last Name *

Requester's Relationship *

Current Address *

City *

State *

Zip *

Phone Number *

Email address *

Identification Document *

All immunization record requests must be accompanied by documents that identify the person requesting the immunization record.

Examples of acceptable forms of identification are a state-issued photo driver's license with address, a state-issued photo identification card with address, or a U.S. passport or passport card with photo.

Upload File:

Recipient Info

By signing this agreement, I hereby authorize the Arizona Department of Health Services (ADHS) to release immunization information that may be held by the Arizona State Immunization Information System of the Arizona Department of Health Services. This information is to be released and sent to the following:

Recipient Type:

Recipient/To the Attention of:

Name of Organization:

Phone Number

Receive By Fax

Fax record to fax number

Fax Number

Receive By Email

Email record to email address

Email address

Requester's Signature: *