Request For Release Of Immunization/medical Records - Our Lady Of Holy Cross College
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1Request for Release of Immunization/Medical Records
I am requesting a copy of my immunization/medical records.
Student’s Name: __________________________
Date of Birth: __________________
(Please Print)
Student ID # (or last 4 digits of Social Security #):_______________________________
Any other names (i.e. maiden) records may be under: ____________________________
_______________________________________________________________________
I would like to have my records:
(Please check one)
_______ Faxed to (phone number):____________________________________
_______ Mailed to (Address): _______________________________________
_______________________________________
_______ Placed in Enrollment Services Office for pick up.
Signature: _______________________________
Date: ______________
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Parent category: Medical