Texas Department of State Health Services TX - dshs texas 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the personal information section. Enter the name of the person receiving the vaccine, including last name, first name, and middle initial.
3. Input the birthdate in the format mm/dd/yy and select the sex by circling either M or F.
4. Complete the address fields: street, city, county, state (TX), and zip code.
5. In the 'For Clinic/Office Use' section, leave space for clinic details such as address, date vaccine administered, manufacturer, and lot number.
6. Sign in the designated area to give consent for vaccination. If you are a guardian, ensure you indicate your relationship.
7. Finally, have a witness sign and date where indicated. Ensure that all information is accurate before submitting.

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