Minor Consent Form

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TEXAS DEPARTMENT OF STATE HEALTH SERVICES
IMMUNIZATION REGISTRY (ImmTrac)
MINOR CONSENT FORM
(Please print clearly)
For Clinic/Office Use
Child’s Last Name
Child’s First Name
Child’s Middle Name
/
/
*Children under 18 years only.
Child’s Gender:
Male
Female
Child’s Date of Birth
Child’s Address
Apartment #
Telephone
City
State
Zip Code
County
Mother’s First Name
Mother’s Maiden Name
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 and stores your child’s (under 18 years of age) immunization
records. With your consent, your child’s immunization information will be included in ImmTrac. Doctors, public health departments,
schools and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed.
The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry.
Consent for Registration of Child and Release of Immunization Records to Authorized Entities
I understand that, by granting the consent below, I am authorizing release of the child’s 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, the
child’s immunization information may by law be accessed by:
• a public health district or local health department, for public health purposes within their areas of jurisdiction;
• a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient;
• a state agency having legal custody of the child;
• a Texas school or child-care facility in which the child is enrolled;
• a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child.
I understand that I may withdraw this consent to include information on my child in the ImmTrac Registry and my consent to release
information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group –
MC 1946, P.O. Box 149347, Austin, Texas 78714-9347.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas
immunization registry.
Parent, legal guardian or managing conservator:
________________________________________________________________________
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. EC-7
Texas Department of State Health Services • ImmTrac Group – MC 1946 • P.O. Box 149347 • Austin, TX 78714-9347
Revised 05/18/2012
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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