Request to Lock My CAIR Record
Complete the fields below. Required fields have an *.
Patient Information
First Name *
Middle Name
Last Name *

Gender *
CAIR Patient ID
(if known)

Patient Address
Street Address *
City *
Zip Code *
Phone * (  -
Relationship To Patient *
Parent/Guardian (if patient is a minor *) 
First Name
Last Name
My/My Child's Health Care Provider *  
Medical Clinic Name
Street Address
Electronic Signature  
By checking this box and entering your name below, you as the Patient/Parent/Guardian confirm your wish to lock this patient's record so that only the patient's medical care provider and public health authorities will be able to view it. You also understand that if in the future, you wish to allow other CAIR users to view the patient record, you will need to complete and submit a Request to Unlock My CAIR Record.
Full Name *  

If you have questions, contact the CAIR Help Desk