Registration And Consent Form

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TEXAS DEPARTMENT OF STATE HEALTH SERVICES
IMMUNIZATION REGISTRY (ImmTrac)
ADULT CONSENT FORM
(Please print clearly)
Last Name
For Clinic/Office Use
First Name
Middle Name
Gender:
Male
Female
Date of Birth
­
­
Address
Apartment #
Telephone
City
State
Zip Code
County
ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure
and confidential service that consolidates immunization records for public health purposes (e.g., giving all doctors treating a patient a central place to see that
patient’s immunization records). With your consent, your immunization information will be included in ImmTrac. For a family member younger than 18
years of age, a parent, legal guardian or managing conservator may grant consent for participation for that minor by completing the ImmTrac Minor
Consent Form (# C-7). The ImmTrac Minor Consent Form (# C-7) can be downloaded by visiting
The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry.
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 state’s central immunization registry, ImmTrac. Once in ImmTrac, 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.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my information in the Texas immunization registry.
Individual (or individual’s legally authorized representative):
Printed Name
Date
Signature
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 for more
information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
Upon completion, please fax or mail form to the DSHS ImmTrac Group or a registered Health-care provider.
Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 •
Stock No. EF11-13366
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P.O. Box 149347 • Austin, TX 78714-9347
Revised 05/18/12
PROVIDERS REGISTERED WITH ImmTrac – Please enter client
information in ImmTrac and affirm that consent has been granted.
DO NOT fax to ImmTrac. Retain this form in your client’s record.

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