Immunization Record Request

Please complete the information listed below to request a copy of your immunization record(s). This is ONLY for immunization records.

*Student Name:

University ID Number:

*Birth Date:

Lewis University Email:

IT makes it here *Last Semester Attended Lewis University

*Fall     Year:     *Spring     Year:

Please send me a copy of my immunization records via (choose one option below):

 Lewis Email 

 Other Email:  

 Fax Number 

 Mailing Address 

Security Password (Please type the word ):