Out of State Vermont Vaccine Record Requests

Vermont Vaccine Record Requests

The Vermont Immunization Registry is a secure database of immunization records. This form is intended for Medical Providers and Health Departments outside of Vermont that need access to a patient's medical records.
Provider/Employee Name*

First NameLast Name
Provider/Employee Email*

Confirmation EmailEnter your email twice to proceed. Both emails must match.
Provider/Employee Phone Number*

Area CodePhone Number
Extension*
*If applicable
Employee Identification*

I.E. scan of a badge
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Facility / Health Department Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's First name*
Patient's Middle name
Optional
Patient's Last name*
Other names used in the past by patient
i.e. maiden name
Patient's Date of Birth*

MonthDayYear

Patient Verification

Examples include intake forms or medical release forms
File Upload*

Intake forms or Medical Releases will be reviewed by the Vermont Department of Health
Cancelof

Is there anything else you would like to add?
How would you like to receive the records*

Secure (encrypted) emailPhone call to discuss
How to Navigate Encrypted Emails

(You cannot access encrypted emails on a smartphone)
Click the "read message" text in the encrypted email.

This will open a new tab in your browser, prompting you to log in to your email.
You will then receive a second email with a passcode, which you will use to access your file(s).

If you are not able to access your file(s), contact us and we can send you copies in the mail if you provide us with your mailing address.
Thank you for your request

After you click submit, we will review your request to do a search and respond with the record(s), if applicable. Please note: some patients over the age of 30 may be missing vaccine records before 1995 in the system. The Immunization Registry went live in 2004, and some older records have not been entered.
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Vermont Vaccine Record Requests