Wisconsin Immunization Registration Form

Did you know that you can have access to your child's vaccine records online? The Wisconsin Immunization Registry, also called WIR, allows patients, parents, and guardians of children to view their vaccine record and keep track of their vaccines. https://www.dhfswir.org/PR/clientSearch.do

To have ongoing access to your child's vaccinations, please complete the following information. We do not collect your child's social security number during patient registration; however, this information is required to gain access to your child's immunizations.

Note: This is a secure, HIPAA compliant form and will not be used for any other purposes.

Please allow 24 hours for processing this request.
The information below should correlate to the child/patient and not the parent/guardian.
Patient Name*

First NameMiddle NameLast Name
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Mother's Maiden Name *
Child's mother's maiden name
Phone Number*
Patient's Social Security Number*
This is the child's social security number. Please ensure accuracy before submitting.
Email*
example@example.com
Signature*

Clear
Date*

MonthDayYear
Date
Requestor's Name*
Relationship to Patient*
Should be Empty: