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PhilaVax Registration
To use the PhilaVax Immunization Information System, you must:

1. Read the PhilaVax User Confidentiality Agreement: https://vax.phila.gov/index.php/documents/philavax-user-confidentiality-agreement/

2. Fill out the form below.

If you are updating your Confidentiality Agreement, no need to do anything - we will update your account and you can keep using PhilaVax.

If you are requesting a new account, a PhilaVax staff member will be in touch with you in about 2 or 3 days with login credentials.

I have read and agree to abide by the PhilaVax User Confidentiality Agreement *
Required
Information about you:
I am a: *
Required
Your first name *
Your answer
Your middle name
Your answer
Your last name *
Your answer
If you are a current or previous PhilaVax user, what is your PhilaVax username?
Your answer
Your title: *
Your answer
Your email address: *
Your answer
Your phone number: *
Your answer
Your fax number:
Your answer
Information about the organization you represent:
Name of the organization you work for: *
Your answer
Organization Mailing Address: *
Your answer
For organizations that are part of the Philadelphia Vaccines For Children (VFC) or Vaccines for Adults At-Risk (VFAAR) Program:
VFC/VFAAR PIN (if applicable)
Your answer
Are you the person responsible for ordering VFC vaccines, or tracking VFC vaccine inventory, in your office?
The information below is only required for licensed medical professionals
National Provider Identification Number (NPI)
Your answer
Medicaid Provider ID
Your answer
PA Medical License Number
Your answer
License Issue Date
MM
/
DD
/
YYYY
License Expiration Date
Your answer
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