IMM Record Request Form

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Proof of identity: All immunization record requests must be accompanied by document(s) that identify the person requesting the immunization record. Examples of acceptable forms of identification include: a state-issued photo driver’s license with address, a state-issued photo identification card with address, a U.S./Foreign passport or passport card with a photo, a school ID, or a Green Card, etc. Please ensure the copy of identification submitted is unexpired and legible. 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.

Processing time: Due to extremely high volumes of record requests, electronic Immunization Record Requests will be processed within 10 business days but may take up to 21 business days. If your request is urgent, please visit your county’s public health department or private provider for possible same day service. This form is generally the quickest way to receive your records from our state office, however if you are unable to submit this form please contact our state office for additional assistance at (404) 657-3158.

Please note: If you received immunizations before the inception of the registry in 2003 , there is a chance those immunizations have not been recorded into the GRITS database. You may try contacting your last physician or healthcare facility where you received immunizations for assistance.

First Name

Middle Name

Last Name

Suffix (Jr, Sr, III, etc.)

Maiden name

Date of Birth

Gender

Male

Female

Mother's First Name

Mother's Last Name

Mother's Maiden Name

Counties in Georgia where immunizations were given (If known) :

Primary Request Reason:

Requestor’s Relationship: (If person is under 18 years of age)

Current Mailing Address:

Current Contact Phone Number:

Email Address:

Attach File: (Please attach a valid and current form of ID and / or any other supporting documents required)
(Maximum file size 5MB and only PDF,PNG, and JPG documents allowed)

Terms & Conditions

I confirm I am legally entitled to receive the vaccine records described in this form

If requestor is a social services agency, healthcare facility, or non-biological parent, include supporting documentation such as: signed medical release; court orders; birth certificates; guardianship/custody; etc., as applicable. Registry information is confidential and will not be released to third parties without proper documentation.

Request for State of Georgia Official Immunization Record

Instructions for completing this Request

Immunization Record requested for:

Requestor’s Information (Person requesting record)