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Replacement Vaccination Card Request Form
Please fill out this form to request a replacement COVID-19 Vaccination Card.

Most of the following questions are to help verify we can locate the correct information in NESIIS (Nebraska State Immunization Information System).
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Legal First Name *
Middle Name or Initial *
Legal Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Email Address (*Put N/A if no email address is available) *
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