Practice Profile

Welcome! Thank you for your interest in the Washington State Immunization Information System (formerly Child Profile Immunization Registry). By submitting the Practice Profile below, we will send you our information packet, as well as the Information Sharing Agreement and Master User Account Application. Please take a moment to complete this information and help us connect to the right person at your practice.


Completing this form does not obligate you in any way. Immunization Information Systemstaff make routine follow up calls to assure that materials have arrived as well as to respond to questions.

Name & Title of person completing this form:
Practice/Clinic Name:
Group/Corporate Name (if applicable):
Mailing Address:

 

CityStateWAZip Code
Name & title of person you would like us to contact:
Telephone:
E-mail:
(This is not a required field, but if you would like to have an email confirmation sent to you please fill in your email address.)
Practice Type:
Pediatric  
Family Practice  
Urgent Care  
Other (Specify)   
Do you have affiliated clinic sites?
Yes  
No  
If Yes, How Many? 
How did you hear about us? (check all that apply)
Immunization Information System staff  
VFC staff  
Newspaper  
Journal article   
Other (specify)   
Best time for staff to call:
Anything else you would like us to know about your practice?