Pre-Registration for Provider / Clinic

Required *

Directions

Facilities with multiple locations should submit a separate pre-registration form for EACH vaccination SITE (rather than licensed provider), unless otherwise approved. Fields with red asterisks are required. You are encouraged to print a copy of this completed form before its submission. Hit the "Submit" button to finish pre-registration.

Site Information

Name of Site being Pre-Registered: *

Name of Prescriber for Site: *
Please provide the name of one of the prescribers (e.g., M.D. or D.O.) under whose authority vaccinations are administered at the site. (Even it the site has multiple prescribers, please list one at this time).

MD DO

Prescriber's Medical License Number: *

Street Address: *
Physical street number and name for the site being pre-registered. (e.g., 108 Lee Street)

Street Address Line #2
Include additional needed information, e.g., Suite 300, Room 400 West.

City:*

State:*

Zip/Postal Code: *

Name of the Person who is the H1N1
Point of Contact (POC) for the Site: *

First Name Last Name

Phone Number for Site's POC: *
Provide the full ten digit number with area code, e.g., 304-344-5243.

Fax Number for Site's POC: *
Provide the full ten digit number with area code, e.g., 304-348-6821.

E-mail Address for Site's POC: *

Type of Site being Pre-Registered: *
Please select only one from the list of options below.

Family Practice

Internal Medicine

Obstetric / Gynecology

Pediatrics

Other:

Your Primary area of practice: *

Same as Above

Other:

Thank You!

By selecting submit, I attest that the information provided, is to the best of my knowledge accurate.

To finish the pre-registration process , hit "Submit" at the bottom after you have completed this form.