COVID-19 Vaccine Card Request Form

COVID-19 Vaccine Card Request Form

Please fill out the below form to request your vaccination records.

Name*
First Last
Email*
Date of Birth*
Month
Day
Year
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
How would you like to receive your records?*
- Mail
- Pickup
Please call (860) 285-1823 to coordinate the day and time of your pickup.