Please complete the form below to request any of the following:

Participant Name

First Name

Last Name

Participant Date of Birth

MM

DD

YYYY

Email

Forms will be sent via encrypted email to this address unless specified below.

What type of information are you looking for?

Please enter the location of the public flu clinic, or the name of the Employer where the flu immunization or biometric screening was held.

What was the approximate date of the flu immunization or biometric screening?

MM

DD

YYYY

Delivery

Include additional information here.

Authorization

Relationship

I am requesting this information for myself.

I am authorized to request this information on behalf of the participant.

By entering your name below, you attest that you are authorized to request or receive information on behalf of the participant described above.

First Name

Last Name

Form Request