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Region of Waterloo Public Health Online Immunization Update Form




Use Detailed Instructions on how to use this online form.
Child Information
Gender: (*)
Select Gender
Parent/Guardian



Add Another Parent's Information

Immunization Header
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
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)