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Select the best category for the assistance you need today?

Please confirm the State you need assistance with today.

Please select your state

Please select your country

Please select your Province or Territory

Please describe your race.

Do you need help getting matched to your state records?

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

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)

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.

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