Florida SHOTS Online Enrollment

Applicant Information

Applicant Last Name:*

Applicant First Name:*

Applicant Middle Name:

Applicant Prefix:

Medical License Number:*

Applicant Email:*

National Provider ID (NPI):

Contact Person Information (for this application)

Contact Last Name:*

Contact First Name:*

Contact Middle Name:

Contact Person Title:

Contact Telephone:*

Contact Fax:

Contact Email:*

Organization Information

Organization Name:*

Organization Category:*

Organization Telephone:*

Organization Fax:

EMR/EHR System:

National Provider ID (NPI):

Vaccine For Children (VFC) PIN: (If currently enrolled in the VFC program.)

Does your Organization Administer Vaccinations?:*

Yes

No

Number of Monthly Vaccinations:*

0-10

11-50

51-100

101+

Patient Type:*

Children

Adults

Vaccine Types Administered:*

DTaP

Influenza

Hepatitis A

Hepatitis B

Meningococcal

MMR

Pneumococcal

Polio

Tdap/TD

Varicella

Physical Address

Physical Address Line 1:*

Physical Address Line 2:

Physical Address City:*

Physical Address State:*

Physical Address Zip Code:*

Physical Address County:*

Validating Physical Address...

Address Validated

Mailing Address

Mailing Address Line 1:*

Mailing Address Line 2:

Mailing Address City:*

Mailing Address State:*

Mailing Address Zip Code:*

Validating Mailing Address...

Address Validated

Signature

Click the blue box to electronically sign this application. *

Signature

Florida SHOTS Online Enrollment

Applicant Information

Contact Person Information (for this application)

Organization Information

Physical Address

Address Validated

Mailing Address Copy From Physical Address

Address Validated

Signature

Applicant Questionnaire

Apply Signature

Title Placeholder

Validate Address

Mailing Address