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Assistance Needed

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Your State

Please confirm the State you need assistance with today.

First Name

Last Name

Phone Number

Date of Birth

Are you of Hispanic, Latino, Spanish Origin?

What is your current ZIP code?

Matching Assistance

Do you need help getting matched to your state records?

Child Matching Assistance

Do you need help getting your children matched to their records?

Please list ALL the children's FULL names and dates of birth.

Please list each child's FULL and complete name and dates of birth: (e.g., John B. Smith 05/01/2005, Mary J. Smith 02/09/2008)

Are you the legal guardian of the child/children listed?

Legal Disclaimer

Legal Disclaimer: Do you request and authorize STChealth to release the immunization information for the patient/child named in this form and understand that the records will be available in MyIR Mobile upon completion of the processing of this form. To accept, select "Yes, I authorize and understand" above, and then click on "Submit" below to send the form. If you do not agree, the form will not be submitted.