IRIS Opt-out

I understand by removing me or my child’s immunization record from IRIS it will not be added to the registry in the future without a written request for IRIS inclusion. Once this information has been deleted it will not be available to my doctor, hospital, childcare facility, school or myself through IRIS. In addition I will not receive any type of reminder notice for recommended immunizations from IRIS. This deletion will not remove records held by your private provider or local health department.

In order to delete your immunization record or your child’s immunization record from IRIS, the information indicated with the * is required. If the individual's name is common (eg. John Smith or Jennifer Jones) please complete all additional fields to ensure the correct individual's immunization information is removed from IRIS.

Today's Date:*

Please complete the information for the person to be deleted from IRIS.

First Name:*

Middle Name:

Last Name:*

Race:

Date of Birth:*

Street Address:

City:

Zip Code :

Mother's Maiden Name :

Guardian's Full Name (If Applicable):

Please provide the information below for the person completing the IRIS deletion form.

Relationship to Child :*

Telephone:

First Name :*

Middle Name:

Last Name:*

Gender:

Date of Birth:*

Street Address:

City:

State:

Zip:

By checking this box I verify the information above is accurate and represents my request to have my information or my child's information deleted from IRIS. I am certifying I have the legal authority to make decisions for the person to be deleted from IRIS.

Signature of Person Requesting Deletion:*

Please Type Security Code the Box :*