* 1. Name of practice:

* 2. Address:

* 3. Telephone Number:

* 4. Fax Number:

* 5. Name of primary contact:

* 6. Email address for practice:

* 7. Facility Type:

* 8. Vaccines for Children (VFC) PIN # (if applicable):

* 9. How do you report to WVSIIS?

* 10. Please list all doctors and vaccinators with credentials (i.e. MD, DO, RN, LPN, MA):

* 11. Please list names of all staff members who currently have access to WVSIIS (include email address if known):

Thank you very much for your cooperation!
Report a problem

T