CURRY HEALTH CENTER
UNIVERSITY OF MONTANA
634 Eddy Avenue, Missoula, MT 59812
Phone: (406) 243-4330
Immunization Records (only) FAX: (406) 243-2254
Request for Immunization Records
If you are requesting only your immunizations (not labs or PPD/TB test) please complete and either mail
or fax to the above. (All other requests need a release of information completed.)
PLEASE PRINT
Date of Birth ________________
Student ID# _______________________________
Patient Name _________________________________________________
Soc Sec# _____________________________
Address ______________________________________________________
Phone (day) __________________________
Dates of Attendance at UM (semester/year to semester/year):
Information to be:
 Mailed
 Faxed
 Picked up
If mailed or faxed: Name:____________________________
Facility:___________________________
Address:__________________________
City:__________________ State:____ Zip________
Phone:____________________________
Fax:______________________________
********************************** For Office Use Only *********************************
Date Requested: _______________
Requested by: ________________
Banner Year: _________________
Medicat Year: ________________
Name Changes: _______________________________
_______________________________
Comments: ______________________________________________________________________
_________________________________________________________________________________
J:\General\Forms\Medical\Medical Office\Request IZ's_2.doc