Follow these steps before submitting this form

  1. Confirm your vaccination record is correct on the CIIS Public Portal
  2. Consider carrying a digital copy of your vaccine card. You can now use the myColorado™ app to access your COVID-19 vaccine record. If you haven't already, download the myColorado™ app and have your Colorado Driver's License or ID ready to set up your account.
  3. If possible retrieve a replacement copy of your card from the location where you received the vaccine.
  4. Contact your Primary Care Physician for a replacement card.
  5. If you are unable to get a replacement card through the location you received the vaccine, your Primary Care Physician, or you are unable to carry a digital copy, fill out the form below.

Your Personal Information

Contact Information


Date and location of vaccination

Where did you receive your first dose (i.e. Pueblo Mall, State Fair, Safeway)?
Where did you receive your second dose (i.e. Pueblo Mall, State Fair, Safeway)?