Immunization Enquiry Form

This form is to be used if you have any questions or concerns regarding your immunization records in the myHSA Patient Portal.

First Name *

Middle Name

Last Name *

Date of Birth *

Email *

Phone *

Please explain the concern with your immunization record *

Please upload a copy of your Immunization Card *
Allowed file types: PDF, JPG, PNG (Maximum size : 5 MB)

File*

I verify that all information submitted is correct.

I have read and agree to the terms & conditions.