How to Fill Out the Texas Immunization Registry Consent Form (ImmTrac2)

The Texas Immunization Registry consent form is a one-page document that authorizes the Department of State Health Services (DSHS) to store your vaccination records in ImmTrac2, the state’s centralized immunization database. Texas is an opt-in state, which means nothing goes into the registry unless you sign the form. There are two versions — one for adults, one for minors — and both are bilingual PDFs available on the DSHS website.

Which Form You Need

DSHS publishes two consent forms, and the right one depends on age:

  • Adult Consent Form: for anyone 18 or older. A legally authorized representative can sign on the adult’s behalf.
  • Minor Consent Form: for children under 18. A parent, legal guardian, or managing conservator signs.

Both were last revised in February 2026 and are posted on the DSHS immunization forms page.1Texas Department of State Health Services. Immunization Forms Your doctor’s office, pharmacy, or local health department should also keep copies. Texas Administrative Code Rule §100.4 requires written consent on an official registry form (paper or valid electronic) before any personal or immunization data can be entered into ImmTrac2.2Texas Department of State Health Services. Texas Immunization Registry: Consent Overview

How to Fill It Out

The adult and minor forms ask for similar information. Print clearly. Illegible handwriting is a common reason forms get kicked back or entered incorrectly at the state level.

Personal Information

Enter the individual’s full legal name (first, middle, last), date of birth, and gender. Add a current mailing address with apartment or building number, city, county, state, and zip code, plus a telephone number and email.3Texas Department of State Health Services. Texas Immunization Registry (ImmTrac2) Adult Consent Form

Two fields trip people up: the mother’s first name and the mother’s maiden name. They aren’t optional. The registry uses them as secondary identifiers to distinguish people with similar names and birth dates. Leave them blank and your form may be returned, or your records may fail to match.

First Responder Status

The adult form has a section asking whether you are a first responder, or an immediate family member (over 18) of a first responder. Check the box if either applies. The designation can affect how certain employers access your records. If neither applies, leave both boxes blank.

Signature

The individual, or their legally authorized representative, must sign and date the form. On the minor form, the parent, legal guardian, or managing conservator signs and indicates their relationship to the child. An unsigned form will not be processed.

Where to Send It

You have three options:

Giving the form to a provider is usually fastest, because they can begin uploading immunization data to ImmTrac2 as soon as consent is on file. If you mail it yourself, allow a couple of weeks. DSHS does not send a confirmation letter. The records simply become visible in the ImmTrac2 portal, and you can confirm enrollment by asking your doctor to pull them up at your next visit. Questions go to the ImmTrac2 line at 800-348-9158.5Texas Department of State Health Services. Contact

When a Minor Turns 18

This is where people quietly lose records they assumed were safe. The minor consent form only covers a child until their 18th birthday. At that point, the now-adult has to sign the adult consent form to keep their childhood immunizations in the registry. Sign it and the records are retained for life.2Texas Department of State Health Services. Texas Immunization Registry: Consent Overview

Skip it and the records sit in limbo. They aren’t deleted right away, but they will be permanently purged before the individual’s 26th birthday.2Texas Department of State Health Services. Texas Immunization Registry: Consent Overview Once purged, they’re gone. Reconstructing a childhood vaccination history from old pediatricians, school nurses, and clinic archives is far harder than signing a one-page form. If you have a teenager approaching 18, put the adult consent form on the transition checklist next to voter registration and the driver’s license.

How Long Adult Consent Lasts

Adult consent does not expire. Once an adult signs, the registry retains their immunization records for life, and any authorized healthcare provider can access and update them.2Texas Department of State Health Services. Texas Immunization Registry: Consent Overview A flu shot at 30 and a tetanus booster at 55 end up in the same consolidated record. That matters most when you move within Texas or switch providers, because the new office can pull your full history without chasing paper records from every clinic you’ve used.

Withdrawing Consent Later

You can remove yourself from ImmTrac2 at any time. DSHS publishes a separate Withdrawal of Consent and Confirmation Form (Stock No. C-8, revised February 2026) for this.6Texas Department of State Health Services. Texas Immunization Registry (ImmTrac2) Withdrawal of Consent and Confirmation Form Mail it to the same ImmTrac2 address: P.O. Box 149347, Austin, TX 78714-9347.

Once processed, DSHS removes all personal and immunization information from the registry, with one exception. Vaccines, antivirals, or other medications administered during a declared disaster or public health emergency are retained for five years after the event ends, regardless of whether you withdraw general consent.6Texas Department of State Health Services. Texas Immunization Registry (ImmTrac2) Withdrawal of Consent and Confirmation Form After those five years, disaster-related records are also deleted unless you specifically consented to keep them longer. Before you withdraw, ask your doctor to print a copy of your record. Once it’s gone, rebuilding it means going provider by provider.