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Vaccine Registration Replacement Form

Replacement Vaccine Card Form

This form is for anyone who received their vaccine card from the Hilo Medical Center, at any of our clinic locations, and needs a replacement.

Please fill out the form below. After verification of records has been confirmed, we will mail a replacement out to the address provided. Please allow 7-14 business days for processing and shipping.

Type your email here
Please Enter your Full name as you would like it to appear on the package
Please enter your date of birth
Please enter your contact number
Please Select where you received your second vaccine. If you did not receive your second shot at either location, please contact the organization where you received it. If you have not yet had a second shot, a new card will be given to you at your second appointment.
Address Line 1  *
Address Line 2
City  *
State or Region  *
Zip  *
Please enter your mailing address