Monkeypox Pre-Registration Form

Organization Name: *
Organization Type: *
Other (specify): **
Do you attest to store, handle, administer, and report JYNNEOS or ACAM2000 vaccines in accordance with the CDC Monkeypox Vaccination Program Provider Agreement ? *(Note: Click to review the Provider Agreement before proceeding.)
Note: Vaccine administration data elements required to be submitted to VIIS will be in accordance with VDH data exchange requirements and inventory and wastage reporting will be through VaxMaX.
Attested by: *
Physical Address
Organization Phone #: *
Fax #:
Address Line 1: *
Zip Code: *
Address Line 2:
City: *
Are you currently using VIIS?: *
If Yes, What is your VIIS Org Code: **
How do you report immunizations to VIIS? *
What is the name of your EMR (Electronic Medical Record): **


    If you are unable to attest to the CDC requirements, you will not be allowed to complete this pre-registration.
Primary Contact Info
Legal First Name*
Last Name*
Middle Initial
ex:(123) 456-7890 - 1234
Backup Contact Info
Legal First Name**
Last Name**
Middle Initial
ex:(123) 456-7890 - 1234

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