Date:  August 17, 2022  

USER AGREEMENT

 TennIIS User Agreement Form
Primary Method of Report:  
PMS Name:
Name of Vendor/Company:
Please list the full name(s) of each new and current staff member who will need to use the web application for the purpose of querying and/or entering immunization data. If you are only using the web application to query ( look up ) records, you only need "view" privileges.
Last Name First Name Phone Email Privileges

  • View Privilege:  means you can only look at the patient record and immunization record(s)
  • Edit Privilege:   means you can view, add and make changes to patient and immunization record(s)
Last Name First Name E-Mail Phone
  Primary Contact:
Type:
First Name, Middle Initial, Last Name:
Phone Number:
Phone Number Extension:
Fax Number:
Email Address: