Under the State of Iowa Administrative Code (653-13.7(8)(2008) and 614.8(2008)) immunizations records for minor child clients must be retained until 1 year after child turns 19. If you may have received an immunization from LCHD before 2000, and would like your record, please fill out the form below. If we are able to locate your record we will contact you. All records will need to be picked up at LCHD (#3 John Bennett Drive) in Fort Madison.

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* 1. Full Name:

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* 2. Maiden Name:

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* 3. Date of Birth:

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* 4. School(s) Attended & Years:

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* 5. Best Way to Contact You (just leave one):

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* 6. By typing my name here I am authorizing LCHD to look for my immunization record, and that the information I provided is mine. Any false information provided on person would be a penalty of perjury.

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