Arkansas WebIZ Help Desk
Arkansas WebIZ Help Desk
Arkansas WebIZ Help Desk
Submit a ticket
I need a user enrollment form to obtain a User account
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
If you have had access in the past, what clinic did you work for?
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:
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Before submitting please make sure of the following:
All necessary information has been filled out.
All information is correct and error-free.
We have:
216.73.216.56 recorded as your IP Address
recorded the time of your submission
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