2022 Mandate Pre-Registration
General
Organization Name:
*
Organization Type:
*
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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):
**
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):
**
Which vaccines do you routinely administer?
*
Would you like to order COVID vaccine for your practice?:
*
Yes
No
Zip
Success!
Contact Info
Contact Type:
*
select
Administrator
VERIP User
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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