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Thank you for using our E-munization Reporting Form.

Please remember to contact us each time your child is immunized.  Parents are responsible for providing this information to us so their child's immunization record is kept current.

Thank you for staying up to date!

  1. Add your child's information below. Be sure to answer all questions marked with a red asterisk (*).

  2. Enter your child's immunization(s). 
  • Refer to your child’s immunization record (e.g., yellow card)
  • Enter the immunization date and check off all the boxes for each immunization given on that date.
  • Repeat for immunizations given on a different date(s) by clicking the “Add Immunization Entry”.
  • Use the vaccine key to help you identify which vaccine was given.
  • To change an existing entry re-enter the date or check/uncheck the checkboxes as needed.
  • To delete an entry row press the black “Delete” button  at the far right of the row.
  • Use the "Other Vaccines and/or Comments" box to type vaccines that are not listed, or to provide us with any additional information. Be sure to include the vaccine name and date it was given.

3. After reviewing the information to make sure it is correct, click "Save and Submit". You will receive an on-screen confirmation that your record was received.

If you have difficulty using this form, please call 519-753-4937 ext. 451 for help.

The content of this item will be sent as an e-mail message to the person or group assigned to the item.