Immunization Record Request

Please complete this form in its entirety. Contact the North Dakota Department of Health (NDDOH) Immunization Program at 701.328.3386 or 800.472.2180 if you have questions.

Please Note: Anyone over the age of 18 must request their own immunization record.

Please allow up to 5 business days for your record request to be processed.

Name of record requested:Date of birth:
(mm/dd/yyyy)
   
Please select one of the following:
Address of where immunization record should be mailed: (if applicable)
 
CityStateZip code
   
Email addressFax numberContact number
   
Name of individual/parent/guardian requesting record:Driver's license number or passport number
  
Relationship to person whose record has been requested: