Practice Profile

Welcome! Thank you for your interest in the CHILD Profile Immunization Registry. By submitting the Practice Profile below, we will send you our information packet, as well as the Information Sharing Agreement and Master User Account Application. Please take a moment to complete this information and help us connect to the right person at your practice.

Completing this form does not obligate you in any way. CHILD Profile staff make routine follow up calls to assure that materials have arrived as well as to respond to questions.

Name & title of person completing this form:
Practice/Clinic Name:
Group/Corporate Name (if applicable):
Mailing Address:
	City State Zip
Name & title of person you would like us to contact:
Telephone:
E-mail:
Practice Type: Pediatric Family Practice Urgent Care Other (specify) Do you have affiliated clinic sites? Yes How many? No How did you hear about us? CHILD Profile staff VFC staff Newspaper Journal article Other (specify) Best time for staff to call: Anything else you would like us to know about your practice?

CHILD Profile
401 Fifth Avenue
Suite 1000
Seattle, WA 98104