Use this form to submit your immunization dates or the immunization dates of your child(ren). When we receive your information, we will update our immunization database accordingly. Please fill in the entire form. All fields marked with a "*" are mandatory fields.
Child's Last Name: *
Child's First Name: *
Child's Birth Name: *
Gender : Male Female*
Date of Birth (MM/DD/YYYY): *
Ontario Health Card Number
  (if the child has one) :
Child's Physician :
School/Day Care (if applicable) :
School/Day Care 2 (if applicable) :
Parent/Guardian Name : *
Parent/Guardian Phone Number : *
Email Address :
Additional Comments/Notes :
Please fill in the boxes beside the vaccine name with the date the vaccine was given. When you are finished, click 'submit'.
VACCINE GIVEN DATE GIVEN
Pentacel
Diptheria, Pertussis,Tetanus, Polio, Haemophilus Influenza B (Hib)
Quadracel
Diptheria, Pertussis, Polio, Tetanus
MMR
Measles, Mumps, Rubella
Varivax/Varilrix
Chickenpox
Prevnar
TWINRIX
Hepatitis A/B
TdPolio
Tetanus, Diptheria, Polio
Adacel
Tetanus, Diptheria, Pertussis
Td
Tetanus,Diptheria
IPV
Inactived Polio
Menomune
Meningococcal Disease
Menjugate
Neis Vac C, Meningitis C
Hepatitis B
Engerix, Recombivax
Menactra
Meningococcal Disease
Other:
Other:
Other:
Other:
Other: