Please complete this form to update contact information associated with yourself or your dependent(s) in the State of Alaska Immunization Information System (VacTrAK).

If you believe that you have duplicate records, this form can also notify Docket support to review your VacTrAK record. 

Updates to phone numbers and email addresses can be made through verification of a valid form of state or federal identification. For any other changes (e.g., first and last name, legal sex, physical/mailing address, or listed vaccinations), please contact your healthcare provider.

This form is HIPAA compliant, and your information will be kept confidential.

Request to update contact information for:

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* 1. Legal First Name

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* 2. Legal Last Name

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* 3. Date of Birth

Date

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* 7. Phone Number (XXX-XXX-XXXX)
This is the number that can be used to verify identity for Docket and will be listed in VacTrAK as the primary number. 

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* 8. Is there an additional phone number you would like added to VacTrAK?

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