Digital Vaccine Card

If you are having trouble accessing your digital vaccine through the state registry at https://myvaccinerecord.cdph.ca.gov/, please fill out the form below.  

Si tiene problemas recibiendo su registro de vacunas digitales en https://myvaccinerecord.cdph.ca.gov/, complete el formulario.

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* 1. Is this your first time filling out this form? | Es su primera vez llenando este formulario?

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* 2. First Name | Primer Nombre:

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* 3. Middle Name | Segundo Nombre:

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* 4. Last Name | Apellido:

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* 5. Date of Birth | Fecha de Nacimiento:

Date

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* 6. Phone Number | Numero de telefono:

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* 7. Address | Domicilio:

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* 8. Email | Correo electronico:

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* 9. Date of first dose | Fecha de primera dosis 

Date

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* 10. Date of second dose | Fecha de segunda dosis

Date
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