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Record Request

This Form is to request Florida Shot Records and Physical Forms for your child. It can also be used to request specific records for your child from our clinic. Please allow 2 Business days for your records to be ready. An email will be sent to confirm they are ready. They will be available for pick up from the front desk.  
Patient Last Name:
Patient First Name:
Date of Birth:
Person requesting records:
Email Address:
Information Requested:
Other request:
Security Code: *  
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