Newborn Registration Form

TEXAS DEPARTMENT OF STATE HEALTH SERVICES

IMMUNIZATION REGISTRY (ImmTrac)

NEWBORN REGISTRATION FORM

(Please print clearly)

For Clinic/Office Use

Child’s Last Name

Child’s First Name

Child’s Middle Name

/

/

*Newborns only.

Child’s Gender:

Male

Female

Child’s Date of Birth

Mother’s First Name

Mother’s Maiden Name

Mother’s Street 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 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.

Please mark the appropriate box

to indicate your choice.

I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas immunization registry.

I DENY consent for registration. I wish to EXCLUDE my child’s information from 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)

Questions? (800) 252-9152 • (512) 458-7284 •

ImmTrac NB-2 Stock No. F11-11936

Texas Department of State Health Services • ImmTrac Group – MC 1946 • P.O. Box 149347 • Austin, TX 78714-9347

Revised 07/22/08

BIRTH REGISTRARS – Please enter newborn client information in

Texas Electronic Registrar and affirm that consent has been granted.

DO NOT fax to DSHS. Retain this form in the client’s birth record.