Maine.gov
DHHS → Request for Demographic Changes in ImmPact
The Maine Immunization Program can change or update your contact information within the ImmPact record. This information will include phone number and email address. All other demographic information changes must be completed by your healthcare provider.
Field marked with * are required.
By entering your full name below, you certify under penalty of perjury that you are the Patient or Parent/Guardian of the minor patient and are therefore authorized to make decisions for the patient listed on this form.