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 http://www.dshs.texas.gov for more information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
PROVIDERS REGISTERED WITH the Texas Immunization Registry: Please enter client information in the Texas Immunization Registry and affirm that consent has been granted. DO NOT fax to the Texas Immunization Registry. Retain this form in your client's record.
Questions? Tel: (800) 252-9152 Fax: (512) 776-7790
Texas Department of State Health Services . Immunizations . Texas Immunization Registry - MC 1946 . P. O. Box 149347 . Austin, TX 78714-9347
Texas Department of State Health Services
Stock No C-7 Revised 02/2022