Vaccine Registration

Name*

First NameLast Name

Date Of Birth*

MM/DD/YYYY

Gender:*

MaleFemale

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Address*

Street Address

County

CityState / Province

Postal / Zip Code

Do you have insurance?*

YesNo

Please input an image of your PRESCRIPTION insurance card or Medicare Part B card.

Please make sure the submitted image is clear

Race (select all that apply)*

Ethnicity (select only one)*

Hispanic or LatinoNot Hispanic or LatinoRecipient Refused

Consent for Registration and Release of Immunization Records to Authorized Persons / Entities
I understand that, by granting the consent below, I am authorizing release of my immunization information to DSHS and I further understand that DSHS will include this information in the Texas Immunization Registry. Once in ImmTrac2, my immunization information may by law be accessed by: a Texas physician, or other health care provider legally authorized to administer vaccines, for treatment of the individual as a patient; a Texas school in which the individual is enrolled; a Texas public health district or local health department, for public health purposes within their areas of jurisdiction; a state agency having legal custody of the individual; a payor, currently authorized by the Texas Department of Insurance to operate in Texas for immunization records relating to the specific individual covered under the payor’s policy. I understand that I may withdraw this consent at any time.

State law permits the inclusion of immunization records for First Responders and their immediate family members (older than 18 years of age) in the Registry. A “First Responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An “immediate family member” is defined as a parent, spouse, child, or sibling who resides in the same household as the First Responder. For a family member younger than 18 years of age, a parent, legal guardian, or managing conservator may grant consent for participation as an “ImmTrac2 child” by completing the Immunization Registry (ImmTrac2) Consent Form (# C-7).

I am a FIRST RESPONDER.I am an IMMEDIATE FAMILY MEMBER (older than 18 years of age) of a First Responder.

By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas immunization registry.

Signature

Printed Name

Date

MM/DD/YYYY

Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)

Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com
Texas Department of State Health Services • ImmTrac Group • MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347

Please Select an Appointment

TEXAS IMMUNIZATION REGISTRY (ImmTrac2)ADULT/MINOR CONSENT FORM

Prevaccination Checklist