Secure Patient Form

Secure Patient Form

This HIPAA Complaint form is the preferred method for existing Vermont Immunization Registry (IMR) users to send Protected Health Information to the Registry Team
This form is intended only for use by medical professionals as well as school and licensed child care that have already applied for access to the Vermont Immunization Registry*

I already have a Registry AccountI do not have a Registry Account
It looks like this requires action on your part. Please click on the appropriate agreement below to gain access to the Registry.
- Health Care and Licensed Child Care Provider Confidentiality Agreement
- School User Confidentiality Agreement
Your name*
Phone Number
Please enter a valid phone number, direct lines preferred
Email*

Confirmation Emailexample@example.com
Patient name as it appears in the Immunization Registry*

First NameLast Name
Date of Birth*

MonthDayYear
File Upload

Use this field to upload a screenshot, if applicable
Cancelof
Please describe what you need assistance with. Be as specific as possible: if there is a vaccine you need us to look at, please indicate below with the date of the dose.
Should be Empty: