Immunization Request Form

Please fill out the form so that we can process the request quickly. Please allow for 2-3 business days for your request to be processed.

By typing my name below I authorize ETBU to release my immunization records to the recipients below.

First

Middle

Last

Date of Birth

Student ID Number

Cell Phone

Home Phone

ETBU email address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Attn: (Name of Recipent One)

Fax

Attn: (Name of Recipent Two)

Fax

Sign here

By signing this form I authorize East Texas Baptist University to release my immunization records to the recipients listed.

Date Submitted 2024-04-25