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Photo of the publication cover. Adult Vaccine Consent Form Immunization - Form September 9, 2019

This form may be used by adult patients aged 19 and older to provide vaccination consent to a healthcare provider.

Adultos Vacuna Formulario de Consentimiento



Photo of the publication cover. VFC Vaccine Administration Form (Part B) Immunization - Form September 9, 2019

This form allows you to provide immunization information for entry into NMSIIS.

VFC Vacuna Forma Administración (Parte B)



Photo of the publication cover. VFC School Immunization Consent Form Immunization - Form August 29, 2019

This is the form to be completed by parents or guardians indicating whether or not a child is to be vaccinated at school.

VFC School Immunization Consent Form (Spanish)



Photo of the publication cover. VaxViewNM Demographic and Contact Information Form Immunization - Form August 19, 2019

VaxViewNM Demographic and Contact Information Form



Photo of the publication cover. Certificate of Exemption from Immunization (ES) Immunization - Form July 30, 2019

This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.



Photo of the publication cover. Certificate of Exemption from Immunization Immunization - Form July 25, 2019

This form may be used by individuals requesting a religious or medical exemption to immunization for their children whom attend any public, private or parochial pre-school, kindergarten, elementary, secondary school, or home school and for children attending daycare of childcare facilities.

Certificate of Exemption FAQ



Photo of the publication cover. VFC Transport Temperature Log Form for Refrigerated Vaccines Immunization - Form February 8, 2019

Complete this log when transporting vaccines to an alternate or back-up refrigerator, or when transferring to another provider.



Photo of the publication cover. NMSIIS Decision to Remove Record Immunization - Form February 6, 2019

This form is used by a patient/parent/legal guardian to remove records from the New Mexico Statewide Immunization Information System.



Photo of the publication cover. NMSIIS Decline to Participate Form Immunization - Form February 6, 2019

This form is used by a patient/parent/legal guardian to decline to participate in the New Mexico Statewide Immunization Information System.



Photo of the publication cover. NMSIIS User Security and Confidentiality Agreement Immunization - Form January 2, 2019

User security and confidentiality agreement for the New Mexico Statewide Immunization Information System.



Photo of the publication cover. NMSIIS Participant Organization Security and Confidentiality Agreement Immunization - Form January 2, 2019

Participant organization security and confidentiality agreement for the New Mexico Statewide Immunization Information System.



Photo of the publication cover. VFC Emergency Vaccine Management Plan Immunization - Form October 17, 2018

The New Mexico VFC Program requires each practice to develop and maintain an Emergency Vaccine Management Plan. Properly completing this template will meet the VFC Program requirement to have a written plan for storage and handling procedures in an emergency.



Photo of the publication cover. School Consent to Enter Student Records into NMSIIS Immunization - Form September 17, 2018

This is a customizable form for use by schools to collect consent from parents so students' historic immunization records may be added to NMSIIS.



Photo of the publication cover. VFC Vaccine Borrowing Form Immunization - Form July 26, 2018

Borrowing vaccines between VFC and State inventories can only take place due to unforeseen delays or circumstances surrounding the vaccines that were ordered. The provider must assure that borrowing VFC vaccines will not prevent a VFC eligible child from receiving a needed vaccination because VFC vaccine was administered to a non-VFC eligible (State) child.



Photo of the publication cover. VFC New Provider Application Immunization - Form March 23, 2018

All VFC providers are required to submit this annual VFC certification form in order to continue receiving VFC vaccines.

VFC Instructions on Digital Signature and Attaching License



Photo of the publication cover. VFC Approved School Sites - Needle, Syringe, & e-kit Order Form Immunization - Form February 23, 2018

This form is to be used for needles/syringes, and e-kit medications and is for Vaccines for Children Approved Sites Only.



Photo of the publication cover. VFC Middle School Vaccination Letter/Permission Form Immunization - Form February 23, 2018

This is the letter addressed to parents or legal guardians to determine whether or not a child is to be vaccinated at school. This letter is to be sent out with the VFC school immunization consent form.

VFC Middle School Vaccination Letter/Permission Form (Spanish)



Photo of the publication cover. VFC Program Data Logger Timeline and Checklist Immunization - Form January 26, 2018

This document is for providers: guidelines and important dates for the transition to digital data loggers.



Photo of the publication cover. VFC Southwest Region Temperature Log Form Immunization - Form January 2, 2018

Catron, Dona Ana, Grant, Hidalgo, Luna, Otero, Sierra, and Socorro



Photo of the publication cover. VFC Southeast (B) Region Temperature Log Form Immunization - Form January 2, 2018

Eddy, Lea, Lincoln, and Roosevelt

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