🕷️ Crawler Inspector

Required field marked with * First Name* First Name Last Name* Last Name Date of Birth* Provide your current mobile phone number. If you fail to get a match using your current mobile phone number, try again using your email address. * Mobile Phone (555) 555-5555 Create a 4-digit PIN. You’ll receive a link to enter the PIN and access your Digital Vaccine Record (DVR). * Note: Your PIN is needed to securely access your DVR. By checking this box, you are declaring under penalty of perjury under the laws of the State of California that you are the Patient or Parent/Guardian of the Patient and are therefore authorized to access the Patient’s immunization record. You are also agreeing to our Terms and Conditions and Privacy Policy and consenting to receive messages from the State of California regarding your vaccination record. By checking this box, I acknowledge that I have received this privacy statement, which is provided in compliance with California Civil Code - Section 1798.17 . The Digital Vaccine Record (DVR) was created by the California Department of Public Health (CDPH) for individuals who wish to receive a digital copy of their California immunization record or a quick response code (QR Code) for use as proof of COVID-19 vaccination. Submitting this form is voluntary. The information collected through this form is necessary to correctly identify your record–not supplying the requested information will prevent you from using the DVR. Your personal information is collected pursuant to Health and Safety Code section 120440 and will be kept confidential and on file as required by law. Please note that any and all information collected in the DVR may be disclosed to the California State Auditor, the California Office of Health Information Integrity, the California Office of Information Security, or other state and federal agencies as required by law. You have the right to review records CDPH maintains about you. CDPH will, upon request, inform you of the location of your records and the categories of persons who use the information in those records. For more information, contact Chief, Immunization Branch, California Department of Public Health, 850 Marina Bay Pkwy, Bldg. P, Richmond, CA 94804 or by phone (800) 578-7889.