Date of birth
Male or Female
Has your child had Covid?
If yes, date of illness:
How were your symptoms?
Mild - Less than 4 days or less of fever greater then 100.4, Less than one week of chills or lethargy
Moderate - 4 days or more of fever greater than 100.4, 1 week or more of chills or lethargy, or a non ICU hospital stay
Severe - ICU stay
Any Cardiovascular symptoms? (Ex: Light headedness, dizziness, shortness of breath, chest pains, etc.)
Guarantor (Parent Information)
Relationship to Patient
Best number to reach you
Which form are you requesting?
TN Department of Health Certificate of Immunization
PAF's Vaccine Administration Record
Excuse Note for Work or School
TSSAA Sports Physical
Boy Scout Form Part C
If faxing, please provide fax number
Who is receiving the fax?
As parent/guardian I give permission to release the requested information. (Clicking this box is your electronic signature)