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  • Add a new Clinic Site

    • Please complete this form and then e-mail it to the Help Desk.
    • Equipment for new network or standalone sites will not be shipped until a modem number has been provided to the state office. This will ensure seamless service and no disruption to the vendor payment system.
    • If you have questions about adding, changing, deleting, or merging sites please call the Help Desk.
    Privacy Statement
    Add a new clinic site

    Clinic Type:
    Co-located with admin. office:
    Immunizations given at this location:
    Appointment Site:
    Lease Space:
    Co-located with MCH or CH:
    Hardware Type
    Add Site to an Existing Laptop?:
Last updated December 08, 2010