Witryna6 kwi 2024 · You may mail the Consent Form to: Texas Department of State Health Service ImmTrac Group T-301 1100 West 49th St. Austin, Texas 78756 Or fax the form to: 512-458-7290 (Austin) 866-624-0180 (toll free) Consent is required to be obtained only one time, and is valid until the child becomes 18 years of age, unless the consent … WitrynaUpon completion, please fax or mail form to the DSHS ImmTrac2 Group or a registered Health-care provider. Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624 …
Workbook: PROVIDER_LOOKUP - Texas
WitrynaDO NOT fax to ImmTrac2. Retain this form in your client’s record. Stock No. F11-12956 Revised 03/2024 Al rellenarlo, mándelo por fax o correo postal al Grupo ImmTrac2 del DSHS o a un proveedor de salud inscrito. ¿Tiene preguntas? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com • ImmTrac2 DC WitrynaWith your consent, your immunization information will be included in ImmTrac2. For a family member younger than 18 years of age, a parent, legal guardian, or managing … sign in without password or pin windows 10
TEXAS IMMUNIZATION REGISTRY (ImmTrac2) ADULT CONSENT FORM
WitrynaUpon completion, please fax or mail form to the DSHS ImmTrac2 Group or a registered Health-care provider. Questions? (800) 252-9152 • (512) 776-7284 • Fax: (866) 624-0180 • www.ImmTrac.com • ImmTrac2 DC Texas Department of State Health Services • ImmTrac2 Group – MC 1946 • P. O. Box 149347 • Austin, TX 78714-9347 Witrynaconsentimiento, los datos sobre sus vacunas se incluirán en el ImmTrac2. En el caso de un menor de 18 años de edad, uno de los padres, el tutor legal o el titular de la custodia puede dar el consentimiento para que ese menor participe. Para ello, deberá llenar el formulario de consentimiento del ImmTrac2 WitrynaUse this form to register your child, aged 17 and younger, in ImmTrac2. Birth registrars: DO NOT use this form. See F11-11936 below. F11-13366. Immunization Registry … sign in without password