Tarrant County Public Healt...

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TARRANT COUNTY PUBLIC HEALTH

Tarrant County Public Health-Immunization Record Request

ImmTrac2 is the Texas Immunization Registry offered by the Texas Department of State Health Services (DSHS). The registry is secure and confidential, and safely consolidates and stores immunization records from multiple sources in one centralized system. As a local health department, Tarrant County Public Health (TCPH) can provide the record to you when you complete this form.

By completing this request form, you agree to the following: (1) Immunization records may indicate the presence of a communicable or noncommunicable disease; (2) Immunization information being reported to and collected by DSHS may not be complete; (3) If you are requesting records for a minor, you must be the parent, legal guardian, or managing conservator for the minor; (4) Anyone 18 years of age or older must request their own record; (5) All requests are subject to TCPH approval/verification. Please allow up to 5 business days to process your request.

If you need assistance in completing this form, you can call the Tarrant County Public Health information line at (817) 248-6299.

Si necesita asistencia para llenar este formulario, por favor llame a la l�nea directa del informaci�n de Tarrant County Public Health (salud p�blica del condado de Tarrant) al 817-248-6299.

Nếu qu� vị cần gi�p đỡ bằng tiếng Việt, qu� vị c� thể gọi đường d�y th�ng tin của Tarrant County Public Health (Y tế C�ng cộng Hạt Tarrant) theo số 817-248-6299.

Information - Person making request

Last Name *

First Name *

Middle Initial

Suffix

Other Names

Gender

Date of Birth *

Phone Number *

Email Address (Used for Communication)

Current Address *

Information about record being requested

Is this request for you or your child? *

Relationship to child

Child's First Name

Child's Last Name

Child's Other Names

Child's Date of Birth

Child's Gender

Did you/your child live at the current address when last vaccinated? *

In order to verify your identity, we need to match your/your child's address.

Address Last Vaccinated at

Have you or your child ever received services from Tarrant County Public Health? *

How would you like to receive your record? *

Email Address Records

Pick-up Clinic

Do you have other shot records that need to be included with this one?

If yes, please attach the shot records here.

What vaccines should be on the record?

The number of COVID-19 vaccines you have received.

The approximate date of at least one COVID-19 vaccine.

The provider, organization name, or location of at least one COVID-19 vaccine administered.

I authorize Tarrant County Public Health to release the official DSHS immunization record for myself or my minor child (if requested). I release Tarrant County Public Health from any legal responsibility or liability that may result from the release of these records.

Signature of Adult Client (or Parent, Legal Guardian, or Managing Conservator for a child)

Type your full name in box below *

Please complete all required fields to submit this request.

Submit Request

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