Alabama Department of Public Health Immunization Forms Requisition for Private Physicians

* Name of Clinic:

* Physician Name:

* Shipping Address:

Mailing Address:
(If different from shipping address)

* Telephone:

* Contact Person:

* Type of Practice:

* Participant in the Vaccines for Children Program (circle):

All Certificates of Immunization (COIs) must be printed directly from ImmPRINT. Blue paper from ADPH is no longer needed. If you need the form for a medical exemption, order the IMM-50.

VFC Vaccine Identification Stickers
Roll of 500

PLEASE ALLOW 2-4 WEEKS FOR DELIVERY

Call 1-800-706-8507 or email questions to immunization@adph.state.al.us