Pre-Registration Form
General
Organization Name:
*
Organization Type:
*
select
Select Organization Type
Adult Care
Child Day Care
Clinic - Private
College/University
Community Health
Correctional Facility/Detention Center
Dialysis
Employee Health
Family Practice
Fire/EMS
FQHC
Free Clinic
Head Start Program
Health Plan
Hospital
Immunization Registry
Internal Medicine
Long Term Care
Military
Mobile Health Clinic
OB/GYN
Other Government
Other Medical Specialty
Other Org
Pediatrician
Pharmacy
Primary Care
Private School
Public Health
Public School
RHC
State
Urgent Care
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.)
Yes
No
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:
*
8/30/2026
Physical Address
Organization Phone #:
*
-
Fax #:
Address Line 1:
*
Zip Code:
*
Address Line 2:
City:
*
State:
Are you currently using VIIS?:
*
Yes
No
If Yes, What is your VIIS Org Code:
**
How do you report immunizations to VIIS?
*
Data Exchange
Manual Entry
Do Not Report
What is the name of your EMR (Electronic Medical Record):
**
Zip
Success!
Warning!
If you are unable to attest to the CDC requirements, you will not be allowed to complete this pre-registration.
Primary Contact Info
Title
Select Title
Dr.
Mr.
Mrs.
Ms.
Miss.
Legal First Name
*
Last Name
*
Middle Initial
Email
*
Phone
*
ex:(123) 456-7890 - 1234
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Backup Contact Info
Title
Select Title
Dr.
Mr.
Mrs.
Ms.
Miss.
Legal First Name
**
Last Name
**
Middle Initial
Email
**
Phone
**
ex:(123) 456-7890 - 1234
-
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