Minor Consent Form
A parent, legal guardian or managing conservator must sign this form if the client is younger than 18 years of age.
The Texas Immunization Registry (ImmTrac2) is a free service of the Texas Department of State Health Services (DSHS). The Texas
Immunization Registry is a secure and confidential service that consolidates and stores your child’s (younger than 18 years of age)
immunization records. With your consent, your child’s immunization information will be included in the Texas Immunization Registry.
Doctors, public health departments, schools, and other authorized professionals can access your child’s immunization history to ensure that
important vaccines are not missed. For more information, see Texas Health and Safety Code Sec. 161.007 (d). https://statutes.capitol.texas.gov/
Consent for Registration of Child and Release of Immunization Records to Authorized Persons/Entities
I understand that, by granting the consent below, I am authorizing release of the child’s immunization information to DSHS and I further
understand that DSHS will include this information in the Texas Immunization Registry. Once in the Texas Immunization Registry, the
child’s immunization information may by law be accessed by a public health district or local health department, for public health purposes
within their areas of jurisdiction; a physician, or other health-care provider legally authorized to administer vaccines, for treating the child
as a patient; a state agency having legal custody of the child; a Texas school or child-care facility in which the child is enrolled; and a payor,
currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child. I understand that I may
withdraw this consent at any time by submitting a completed Withdrawal of Consent Form in writing to the Texas Department of State
Health Services, Texas Immunization Registry.
State law permits the inclusion of immunization records for First Responders and their immediate family members in the Texas Immunization
Registry. A “First Responder” is defined as a public safety employee or volunteer whose duties include responding rapidly to an emergency. An
“immediate family member” is defined as a parent, spouse, child, or sibling who resides in the same household as the First Responder. For more
information, see Texas Health and Safety Code Sec. 161.00705. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.161.htm#161.00705.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas Immunization Registry.
Parent, legal guardian, or managing conservator:
Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas
collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency
to correct any information that is determined to be incorrect. See http://www.dshs.texas.gov
for more information on Privacy Notification.
(Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)
PROVIDERS REGISTERED WITH the Texas Immunization Registry: Please enter client information in the Texas Immunization
Registry and affirm that consent has been granted. DO NOT fax to the Texas Immunization Registry. Retain this form in your client’s record.