ImmPRINT

New User Registration

Fields marked with an asterisk (*) are required.

Medical Authority - Can authorize a vaccination | Vaccinator - Administers vaccinations | User - Uses ImmPRINT application to enter or read vaccination information
Use full legal name. Do not use shortened versions, nick names or abbreviations

User Information

Check here if you are working directly for an EMR vendor

First Name*

Middle Name

Last Name*

Last 4 Digits of SSN*

Email*
- Not a Valid E-Mail Address

Confirm Email*
Required: Email Not a Valid Email

Primary Site Information

Site Type*

County*

Site*
Please Select Site

Medical Authority/Vaccinator/User*

Professional Title*

Please enter a License Number

Password must be a minimum of 8 characters and contain at least 3 of the following

Uppercase characters
Lowercase characters
Digits (0-9)
Nonalphanumeric characters: (~!@#$%^&*_-+=`|\(){}[]:;<>,.?/)

Preferred Login ID*

Password*

Confirm Password*