ROW Public Health Logo Region of Waterloo Public Health Online Immunization Update Form


Please click here for detailed instructions on how to use this online form.
Child Information
First Name: (*)
Last Name:(*)
Middle Name:
Gender:(*)
Date of Birth:(*) MM/DD/YYYY  
Address:(*)
City:(*)
Postal Code:
School or Daycare Name:
Ontario Health Card Number:
Parent/Guardian:
First Name: (*)
Last Name:(*)
Same Address as Child
Address:(*)
City:
Postal Code:
Home Phone:(*)
Work Phone: ext.
Cell Phone:


Add Another Parent's Information

Add Immunization

If your yellow card has the vaccine brand name written on it and no boxes checked off, use the Immunization Key below or simply enter the immunization brand name in the “other” section." The client could then click on the Immunization Key hyperlink to call up the document.



Notice of Purpose – Personal Health Information: By completing this form, you are consenting to the collection and use of your personal health information by Region of Waterloo Public Health to maintain the provincial immunization database. For further information, please contact the Director of Central Resources 519-883-2000.

PLEASE NOTE: Some browsers may have difficulty interpreting this form. Please make sure all of the columns line up properly before you submit your information.
Please correct the following errors prior to submitting your informationg your information
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Detailed Instructions Please note that all red "*" entries are required fields and must be completed before you are able to submit the record.
1. Complete the “Child Information” section. Enter as much information as possible. If your child is in school, or a child care facility, please enter this information.
2. Enter the “Parent/Guardian Information” section. • If the child lives at the same address as the parent select “Same Address as Child.” The address fields in this will section will then be automatically completed for you. • If there is more than one parent/guardian, select “Add Another Parent's Information” and complete this section.
3. You will only be able to enter one immunization date at a time on the “entry line”. Please enter the specific immunization date (include year, month and day) and check off all the immunizations given on that date. If your yellow card has the vaccine brand name written on it and no boxes checked off, use the Immunization Key below or simply enter the immunization brand name in the “other” section.
4. After you have entered the date and name of the vaccine(s), press the “add” button to complete the vaccine entry for that date and also enter additional immunization date(s). You can make any edits or changes at any point before selecting “submit.”
5. After you have entered all your immunization dates, check the entire form to ensure you have not make any mistakes. If the information is correct press the "submit" button. The “submit” button will send your information to Region of Waterloo Public Health. You will receive a pop-up message informing you that your information was received.
6. If you are experiencing any trouble, or do not understand how to use this online form, please contact 519-575-4400 ext. 13009. Please note this line is staffed Monday to Friday, 8:30 a.m. to 4:30 p.m.
Vaccine Brand Names Available Infectious Disease(s) it protects against
 Adacel or Boostrix  Diphtheria, pertussis, tetanus
 Recombivax Pediatric  Hepatitis B for children from birth-12yrs, and from 16yrs-18yrs
 Engerix or Recombivax  Hepatitis B- for adults and children 13-15 yrs.
 Fluviral or Agriflu or Fluad or Vaxigrip  Influenza (Flu) 
 Gardasil or Cervarix  Human Papillomavirus (HPV) 
 BCG  Tuberculosis
 Hib  Haemophilus influenzae type B
 Priorix-Tetra  Measles, Mumps, Rubella, Varicella (Chicken Pox)
 Imovax  Polio 
 Avaxim or Havrix 1440  Hepatitis A for Adults
 Havrix 720  Hepatitis A for children (or as booster dose for adults)
 Menomune  Meningococcal type ACYW135 (meningitis) Polysaccharide
 Menactra  Meningococcal type ACYW135 (meningitis) conjugate
 Menjugate or Neisvac  Meningococcal type C (meningitis) conjugate
 MMR II or Priorix  Measles, Mumps, Rubella
 MMRV or Priorix-Tetra  Measles, Mumps, Rubella, Varicella (MMRV)
 OPV (oral)  Polio
 Pediacel or Pentacel  Diphtheria, Pertussis, Tetanus, Polio and Haemophilus influenzae type b (hib)
 Pneumovax 23 or Pneumo 23  Pneumococcal infections (meningitis, blood infection, pneumonia) (Polysaccharide)
 Prevnar 13 or Synflorix  Pneumococcal infections (meningitis, blood infection, pneumonia) (conjugate)
 Quadracel  Diphtheria, Pertussis, Tetanus, Polio
 Rotarix or Rotateq  Rotavirus
 Td  Tetanus, Diphtheria
 TdP  Tetanus, Diphtheria, Polio
 Twinrix  Hepatitis A and B for adults
 Twinrix Jr.  Hepatitis A and B for children
 Varivax or Varilrix  Varicella (Chickenpox)