MINOR Consent Form
ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The immunization registry is a secure and confidential service that consolidates and stores your child’s (under 18 years of age) immunization records. With your consent, your child’s immunization information will be included in ImmTrac. Doctors, public health departments, schools and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed.
The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry.
I understand that, by granting the consent below, I am authorizing release of the child’s immunization information to DSHS and I further understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac”). Once in ImmTrac, the child’s immunization information may by law be accessed by:
I understand that I may withdraw this consent to include information on my child in the ImmTrac Registry and my consent to release information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group – MC 1946, P.O. Box 149347, Austin, Texas 78714-9347.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas immunization registry.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Parent, legal guardian or managing conservator:
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. Seehttp://www.dshs.state.tx.usformore information on Privacy Notification.(Reference:GovernmentCode,Section552.021,552.023,559.003and559.004)
Your information will be encrypted.