Arkansas WebIZ Help Desk
Arkansas WebIZ Help Desk
Arkansas WebIZ Help Desk
Submit a ticket
User Enrollment Request
Submit a Support Request
Required fields are marked with
Name:
Email:
Confirm Email:
ARE YOU NEEDING A USER ENROLLMENT FORM?
YES
NO
**THIS TICKET IS FOR ENROLLMENT ONLY.
IF YOU ARE NEEDING CHANGES TO YOUR EXISTING ACCOUNT,THIS IS NOT THE RIGHT TICKET.
PLEASE SUBMIT A TICKET UNDER "I NEED HELP WITH MY USER ACCOUNT"
Have you ever had access to the Registry in any capacity?
Yes
No
Job Title:
Do you administer vaccinations?
yes
no
Do you prescribe vaccinations?
yes
no
Facility name:
Facility Phone Number:
What is the best number to reach you at?
store# / clinic# (ex: Walmart #1):
Tell us why you need access:
Subject:
Message:
Suggested knowledgebase articles:
Attachments:
Add file
File upload limits
SPAM Prevention
Type the number you see in the picture below.
Before submitting please make sure of the following:
All necessary information has been filled out.
All information is correct and error-free.
We have:
44.222.134.250 recorded as your IP Address
recorded the time of your submission
(
)