COVID-19 Vaccine Documentation Request- FIU STUDENTS ONLY

Please complete this form if you are an FIU student who needs documentation of your COVID-19 vaccination.

NOTE: We can only provide replacement cards if you received your vaccine in the state of FL.

If you received your vaccine in another state other than Florida, please contact your vaccine provider site directly or your state health department's immunization information system.
Date of Request: Date of Request: / MM / DD YYYY
Name Name First Last
Panther ID#
Date of Birth Date of Birth / MM / DD YYYY
Email
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Please select one or more of the following options:

Please select one or more of the following options: Replacement COVID-19 Vaccination Card Florida SHOTS Record
The replacement card will be available in 3 business days, not including the day of submission of this form at the MMC Student Health Medical Records. If you are at BBC, please call 305-348-8385 AFTER you submit the form and request for the card to be sent to the BBC campus.
Draw your signature into the box below. By signing this document, I am allowing the FIU Student Clinic to run my record through the FL SHOTS state immunization database. I understand this is a legal representation of my signature. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.