Fax form

Immunization record request
For your convenience, use this form to fax your request for a child's immunization record.

Of course, you may always call your primary office to request prescription refills.

Instructions
Print this form. Please be sure to fill out all the blanks to ensure proper processing of your request. Fax it to your primary office below.

• Download this pdf form and print it using Adobe Acrobat Reader.

Primary office fax numbers:

Camillus office FAX: (315) 487 - 3485

Liverpool office FAX: (315) 652 - 4679

Please fill out completely

Patient / parent information

Patient's name: ________________________________________________________

Patient's birthday: __________________________________________________

Primary care physician: _________________________________________________

Parent's name: ____________________________________________________

Address: _____________________________________________________________

Phone number: ____________________________________________________