Electronic Confirmation

Patient Information

Last Name: *

First Name: *

Middle Name:

Suffix:

Date of Birth: *

Street Address: *

City: *

State: *

Zip Code: *

Phone Number: *

E-mail Address:

Requestor Information

Relationship
to Patient: *

Self

Last Name: *

First Name: *

Middle Name:

Suffix:

Date of Birth: *

Street Address: *

City: *

State: *

Zip Code: *

Phone Number: *

E-mail Address:

Information to be Disclosed *

Immunizations

Method of Disclosure * (Select one item from the list below)

Fax

E-mail

E-mail Address:

Purpose of Disclosure * (Select one item from the list below)

Continuity of Care

Personal Use

Other (Specify)

Requestor Identity Proof

In order to prove your identity, you will need to upload a picture of a
Driver's License, State-Issued ID card, or other photo proof in the fields below.

Accepted file formats:

JPG, JPEG, TIF, TIFF and PDF

File size limits:

2.5 MB

Primary ID Type: *

Other ID Type: *

Primary ID File: *

Secondary ID Type:

Other ID Type: *

Secondary ID File: *

Electronic Signature

By checking this box and by entering your full name below, you are declaring
that you are authorized to access this immunization record. * I am authorized to access this patient's immunization record * I am authorizing the Florida Dept. of Health to release this immunization record to me.

Full Name: *

Date:

04/19/2024

Thank you for submitting the record request form. Your record access PIN is .
Please have it as a reference when contacting the Record Request Help Desk.

Your request will be processed in 10-12 business days and the record will be released only if the information provided in the record request form matches the information found on the patient record in Florida SHOTS.
We will contact you if any additional information might be needed to positively match your request to a patient record.

Click here to download the electronically signed record request form DH 3203 for your records.