myvaccinerecord.cdph.ca.gov
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Submitted URL: https://5br56v5b.r.us-west-2.awstrack.me/L0/https:%2F%2Fmyvaccinerecord.cdph.ca.gov/2/02010000d1t1j2f0-a3b7mofl-q1f9-obsh-h8s2-l0dd9k5pub...
Effective URL: https://myvaccinerecord.cdph.ca.gov/
Submission: On July 26 via manual from US — Scanned from US
Effective URL: https://myvaccinerecord.cdph.ca.gov/
Submission: On July 26 via manual from US — Scanned from US
Form analysis 1 forms found in the DOM
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<div class="MuiCardContent-root" style="padding: 16px 12px;">
<h2 class="covid-card-header">Please fill out the required fields to receive a link to a QR code and digital copy of your COVID-19 vaccination record:</h2>
<div style="margin-bottom: 15px;">
<p class="MuiTypography-root MuiTypography-body1">Required fields marked with *</p>
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<div class="MuiFormControl-root MuiTextField-root col-12" aria-label="First Name"><label class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated Mui-required Mui-required" data-shrink="false" for="FirstName"
id="FirstName-label">First name<span aria-hidden="true" class="MuiFormLabel-asterisk MuiInputLabel-asterisk"> *</span></label>
<div class="MuiInputBase-root MuiInput-root MuiInput-underline MuiInputBase-formControl MuiInput-formControl"><input aria-invalid="false" id="FirstName" name="FirstName" required="" type="text" maxlength="30" dir="ltr"
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<div class="MuiFormControl-root MuiTextField-root col-12" aria-label="Last name"><label class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated Mui-required Mui-required" data-shrink="false" for="LastName"
id="LastName-label">Last name<span aria-hidden="true" class="MuiFormLabel-asterisk MuiInputLabel-asterisk"> *</span></label>
<div class="MuiInputBase-root MuiInput-root MuiInput-underline MuiInputBase-formControl MuiInput-formControl"><input aria-invalid="false" id="LastName" name="LastName" required="" type="text" maxlength="30" dir="ltr"
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<div class="MuiFormControl-root MuiTextField-root col-12" aria-label="Date of birth"><label class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated Mui-required Mui-required" data-shrink="false" for="dob"
id="dob-label">Date of birth<span aria-hidden="true" class="MuiFormLabel-asterisk MuiInputLabel-asterisk"> *</span></label>
<div class="MuiInputBase-root MuiInput-root MuiInput-underline MuiInputBase-formControl MuiInput-formControl MuiInputBase-adornedEnd"><input aria-invalid="false" id="dob" name="DateOfBirth" placeholder="MM/DD/YYYY" required="" type="text"
dir="ltr" class="MuiInputBase-input MuiInput-input MuiInputBase-inputAdornedEnd" value="" style="text-align: left;">
<div class="MuiInputAdornment-root MuiInputAdornment-positionEnd"><button class="MuiButtonBase-root MuiIconButton-root" tabindex="0" type="button" aria-label="Date of birth"><span class="MuiIconButton-label"><svg class="MuiSvgIcon-root"
focusable="false" viewBox="0 0 24 24" aria-hidden="true">
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<fieldset class="MuiFormControl-root" style="margin-top: 50px;">
<legend class="MuiFormLabel-root">Provide a mobile phone or email that may be associated with your vaccine record. If you fail to get a match using your mobile phone, try again using your email address.</legend>
<div class="MuiFormGroup-root MuiFormGroup-row" role="radiogroup" aria-label="contact type"><label class="MuiFormControlLabel-root" aria-label="Mobile Phone Selector"><span
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<path d="M8.465 8.465C9.37 7.56 10.62 7 12 7C14.76 7 17 9.24 17 12C17 13.38 16.44 14.63 15.535 15.535C14.63 16.44 13.38 17 12 17C9.24 17 7 14.76 7 12C7 10.62 7.56 9.37 8.465 8.465Z"></path>
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</span><span class="MuiTouchRipple-root"></span></span><span class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Mobile Phone</span></label><label class="MuiFormControlLabel-root" aria-label="Email Selector"><span
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name="Email" type="radio" aria-label="Email" value="Email">
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<path d="M8.465 8.465C9.37 7.56 10.62 7 12 7C14.76 7 17 9.24 17 12C17 13.38 16.44 14.63 15.535 15.535C14.63 16.44 13.38 17 12 17C9.24 17 7 14.76 7 12C7 10.62 7.56 9.37 8.465 8.465Z"></path>
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</span><span class="MuiTouchRipple-root"></span></span><span class="MuiTypography-root MuiFormControlLabel-label MuiTypography-body1">Email</span></label></div>
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<div class="MuiFormControl-root MuiTextField-root"><label class="MuiFormLabel-root MuiInputLabel-root MuiInputLabel-formControl MuiInputLabel-animated Mui-required Mui-required" data-shrink="false" for="contactPhone"
id="contactPhone-label">Mobile Phone<span aria-hidden="true" class="MuiFormLabel-asterisk MuiInputLabel-asterisk"> *</span></label>
<div class="MuiInputBase-root MuiInput-root MuiInput-underline MuiInputBase-formControl MuiInput-formControl" dir="ltr"><input aria-invalid="false" id="contactPhone" name="textmask" placeholder="(555) 555-5555" required="" type="tel"
class="MuiInputBase-input MuiInput-input" value="" style="text-align: left;"></div>
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</div>
<legend class="MuiFormLabel-root" style="color: dimgrey; margin-top: 50px;">Create a 4-digit PIN. You'll receive a link to enter the PIN and access your digital vaccine record. *</legend>
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<div class="MuiInputBase-root MuiInput-root MuiInput-underline jss24 MuiInputBase-formControl MuiInput-formControl"><input aria-invalid="false" autocomplete="off" id="partitioned" name="PIN" required="" type="tel" dir="ltr" maxlength="4"
minlength="4" class="MuiInputBase-input MuiInput-input" value="" aria-label="Set 4 Digit Pin" style="text-align: left;"></div>
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</div><label for="partitioned" style="color: red;"></label>
<div style="margin-bottom: 50px; margin-top: 20px;"><span style="background: rgb(34, 72, 156); border-radius: 5px; color: rgb(255, 255, 255); padding: 0px 5px 1px; margin-left: 0px;">Note:</span> Your PIN is needed to securely access your
digital record.</div>
<div style="display: flex;"><label class="MuiFormControlLabel-root" for="submitcheckbox" aria-label="Policy Agree Checkbox"><span
class="MuiButtonBase-root MuiIconButton-root jss25 MuiCheckbox-root MuiCheckbox-colorPrimary MuiIconButton-colorPrimary" aria-disabled="false" style="align-self: start; margin-top: -5px;"><span class="MuiIconButton-label"><input
class="jss28" id="submitcheckbox" name="submitChecked" type="checkbox" data-indeterminate="false" value="" aria-label="Acknowledge Button"><svg class="MuiSvgIcon-root" focusable="false" viewBox="0 0 24 24" aria-hidden="true">
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<div>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.</div>
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<div class="MuiCardActions-root MuiCardActions-spacing" style="margin-bottom: 30px; padding: 8px 0px;"><button type="submit" aria-label="submit" disabled=""
style="border-radius: 20px; padding-left: 20px; padding-right: 20px; background-color: rgb(189, 189, 189); color: white; margin: 0px;">Submit</button></div>
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</form>Text Content
You need to enable JavaScript to run this app. Skip to main content State of California * English * Español * 简体字 More Digital COVID-19 Vaccine Record WELCOME TO THE DIGITAL COVID-19 VACCINE RECORD (DCVR) PORTAL Get a digital copy of your vaccine card. Just enter a few details below to get a link to a QR code. Save it on your phone and use it as proof of vaccination wherever you go. If you are a parent or guardian and have multiple vaccine records associated with a single mobile number or email address, enter each digital vaccine record request separately. NOTE: If you received your vaccinations from a federal agency (e.g., Department of Defense, Indian Health Services, or Veterans Affairs), you will need to contact those agencies for assistance with your vaccination record. If you have questions about your Digital COVID-19 Vaccine Record, visit our FAQ. -------------------------------------------------------------------------------- PLEASE FILL OUT THE REQUIRED FIELDS TO RECEIVE A LINK TO A QR CODE AND DIGITAL COPY OF YOUR COVID-19 VACCINATION RECORD: Required fields marked with * First name * Last name * Date of birth * Provide a mobile phone or email that may be associated with your vaccine record. If you fail to get a match using your mobile phone, try again using your email address. Mobile Phone Email Mobile Phone * Create a 4-digit PIN. You'll receive a link to enter the PIN and access your digital vaccine record. * Note: Your PIN is needed to securely access your digital record. 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. Submit -------------------------------------------------------------------------------- Safe, free, and effective COVID-19 vaccines are now available to everyone ages 5 and up.Get vaccinated. * * CA.gov home * Conditions of Use * Privacy Policy * Accessibility * FAQ * Contact Us Copyright © 2022 State of California * Tagalog * Tiếng Việt (Vietnamese) * 한국어 (Korean) * 繁體字 (Traditional) * العربية (Arabic)