MyVaxIndiana

Step 1: Enter Your Information

Requestor First Name: Letters Only!*

Requestor Last Name: Letters Only! *

Patient Date of Birth:

Requestor Email Address: * *

Requestor Confirm Email: * *

Please keep my email address for future vaccine reminders from the Indiana State Department of Health

Step 2: Enter Security Info & Agree

PIN #:
*

Generate New Image

Type the code from the image:

By clicking this box I agree to patient confidentiality and I declare under the penalty of perjury under the laws of the State of Indiana that the foregoing is true and correct. I understand that the immunization record to be disclosed will be disclosed in accordance with this authorization and within Indiana Code 16-38-5-3. I am authorized to view this record as an individual or as the guardian of the record I am requesting.

The information provided by MyVaxIndiana is supplied by the Children and Hoosier’s Immunization Registry Program (CHIRP). For any changes to a record including address changes and missing or incorrect vaccine dates, please contact your Medical Provider, Local Health Department, or the ISDH Immunization Program.