Office of the Registrar - Cape Cod Community College - Student Immunization Records
2240 Iyannough Road, West Barnstable, MA 02668
774-330-4331 / Fax 508-375-4039 /
Immunization Records Request Form
HEALTH RECORD RETENTION POLICY: All students are encouraged to establish a personal file for
their medical records. Immunization documents are retained by the college for five (5) years only and
Requests will be processed within 10 business days.
Student ID #:
Other/Maiden Name(s) :
Date of Birth: (mm/dd/yyyy)
Phone: Dates of Attendance:
Check all that apply :
□ I will pick up a copy of my immunization records. Please call me when they are ready at the number listed above.
□ Please mail a copy of my immunization records to my address listed above.
□ Please fax a copy of my immunization records to:
Name and Number:
□ Please forward a copy of my immunization records to:
FOR OFFICE USE ONLY:
This fax/e-mail, including any attachments, may be intended solely for the personal and confidential use of the sender and
recipient (s) named above. This message may include advisory, consultative and/or deliberative material and, as such, would be
privileged and confidential under HIPAA regulations and not a public document. Any information in this fax/e-mail identifying a
student of Cape Cod Community College is confidential. If you have received this fax/e-mail in error, you must not review,
transmit, convert to hard copy, copy, use or disseminate this fax/e-mail or any attachments to it and you must delete this
message. You are requested to notify the sender by return e-mail. Thank you.
**THIS INFORMATION IS PRIVATE & CONFIDENTIAL*
4/2/12 slg 2/2/18 st
click to sign
click to edit