Health Compliance FL SHOTS Consent Form and Portal Access Request

If you were vaccinated in the State of Florida, Health Compliance may be able to locate your records and facilitate your registration process. By completing this form you are allowing Health Compliance to run your information through the FL SHOTS state immunization database. If HC is able to locate your immunization information, this may facilitate your registration process.

Student Name: Student Name: First Last
Panther ID:
Date of Birth: Date of Birth: / MM / DD YYYY
FIU Email:
Other Email:
Phone Phone - ### - ### ####
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please select your student status:

Please select your student status: Incoming Freshman Transfer Transient Other
Please select term when you are entering FIU:

Please select term when you are entering FIU: Summer Fall Spring Other
Year of Starting Semester (ex. 2023)
Sex

Sex Male Female Other
Draw your signature into the box below. By signing this document, I am allowing Health Compliance to run my record through the FL SHOTS state immunization database. I understand this is a legal representation of my signature.

Draw or Type

By signing this document, I am allowing Health Compliance to run my record through the FL SHOTS state immunization database. I understand this is a legal representation of my signature. Clear

Full Name

By signing this document, I am allowing Health Compliance to run my record through the FL SHOTS state immunization database. I understand this is a legal representation of my signature.