Immunization Record Request Form

  • Virginia Immunization Information System (VIIS)

    Immunization Record Request Form

    Please provide complete information below to receive an immunization record. A VIIS representative will contact you within 24 to 48 hours to discuss your request.

    To assists in your immunization record request being processed promptly:

    • Only submit one immunization record request per client.
    • Be available and responsive to calls and/or emails.
    • Make sure telephone numbers and emails are correct before submitting request.

    VIIS Record Request

    • IMMUNIZATION RECORD REQUEST FOR:

    • REQUESTOR'S INFORMATION:

    • This field is for validation purposes and should be left unchanged.