2022 Mandate Pre-Registration

Organization Name: *
Organization Type: *
Other (specify): **
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): **
Which vaccines do you routinely administer? *
Would you like to order COVID vaccine for your practice?: *


Contact Info
Contact Type*
Legal First Name*
Last Name*
Middle Initial
ex:(123) 456-7890 - 1234

Please enter the captcha to submit the form.

Processing the data, please wait...
    You must select at least one measure?