FL Immunization Screening Portal

Welcome to the official Florida Department of Health online Immunization forms processing portal!!!

Immunization Form

All fields/sections marked with (*) sign are required.

Select Language

Select Service County*

Refugee Health*

First Name*

Middle Name

Last Name *

Date of Birth *

Gender*

Ethnicity *

Race *

State of Birth

Country of Birth (If not USA)

Street Address 1*

Street Address 2

City*

State*

Zip Code*

County*

Phone Number*

PhoneType Home Cell

Allergies

Allergies

Other Allergies

Required Information for Childhood Services

Parent First Name*

Parent Last Name *

Relationship to Child*

Reason for Visit*

Other Reason for Visit

Grade

Vaccines for Children Eligibility / Insurance

Insurance Details

Adult Services

Where are you traveling to ? *

How long will you be gone ? (in Days) *

Will you be staying in any other country for more than 12 hours ? If yes, what country ? *

Yes

If you have any of the below health conditions, please contact our nursing staff at 407-665-3281 to discuss prior to your appointment:

Chronic health problems

Immune system disorders

Brain or nervous system problems or seizures

Take the following medication: steroids, anti-cancer drugs, antibiotics, rheumatoid arthritis drugs, long-term aspirin therapy, Crohn's disease or psoriasis

Radiation treatments in past 3 months

Blood transfusion gamma globulin or an antiviral drug in last year

CHILD AND ADULT SCREENING: Please mark if any of the following apply today to the client to be seen.

Upload Documents (Supported documents JPEG, JPG or PDF)

Previous Immunization Record:

Choose file

Parent/Guardian Government Issued ID with Picture*:

Choose file

Ex. Driver’s license, passport, birth certificate, Identification card

Previous Immunization - 2:

Choose file

Miscellaneous Upload:

Choose file

Ex. Legal guardianship document, additional vaccine records

Birth Certificate*:

Choose file

Miscellaneous Upload 2:

Choose file

Ex. Legal guardianship document, additional vaccine records

Email*

Signature Date

FL Immunization Screening Portal

System Support

FL Immunization Screening Portal

Welcome to the official Florida Department of Health online Immunization forms processing portal!!!

Immunization Form

Upload Documents (Supported documents JPEG, JPG or PDF)