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    Notification of Vaccination Letter Template: Vaccines Administered

    Uploaded by

    Jacob Buck
    This letter notifies a patient's primary care clinic of vaccines administered. It lists the patient's name, date of birth, vaccines received including dose and administration route. The providing clinic's contact information is included so the patient's medical record can be updated. The clinic wants to ensure the primary care clinic has accurate vaccination information and to contact them with any questions.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Notification of Vaccination Letter Template: Vaccines Administered

    Uploaded by

    Jacob Buck
    281 views1 page
    This letter notifies a patient's primary care clinic of vaccines administered. It lists the patient's name, date of birth, vaccines received including dose and administration route. The providing clinic's contact information is included so the patient's medical record can be updated. The clinic wants to ensure the primary care clinic has accurate vaccination information and to contact them with any questions.

    Original Description:

    Template 3060.32

    Original Title

    p3060

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    This letter notifies a patient's primary care clinic of vaccines administered. It lists the patient's name, date of birth, vaccines received including dose and administration route. The providing clinic's contact information is included so the patient's medical record can be updated. The clinic wants to ensure the primary care clinic has accurate vaccination information and to contact them with any questions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    281 views1 page

    Notification of Vaccination Letter Template: Vaccines Administered

    Uploaded by

    Jacob Buck
    This letter notifies a patient's primary care clinic of vaccines administered. It lists the patient's name, date of birth, vaccines received including dose and administration route. The providing clinic's contact information is included so the patient's medical record can be updated. The clinic wants to ensure the primary care clinic has accurate vaccination information and to contact them with any questions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Notification of Vaccination Letter Template

    Dear doctor or nurse at


    patient’s primary care clinic

    We recently provided vaccination services to your patient. We want to make certain that you
    have information about the vaccines we administered so you can update your patient’s medical
    record. Please contact us if you have any questions about this information.
    We provided the patient (or parent/guardian) with a written record of the vaccination(s) given.
    We entered information about the vaccine(s) we administered in the regional or state
    immunization information system.

    Patient’s name Patient’s birthdate


    (mm/dd/yr)

    (For a child, parent/guardian name Parent/guardian birthdate )


    (mm/dd/yr)

    The vaccine(s) we administered on is/are checked below.


    date

    vaccines administered
    Hepatitis B IPV (Polio) Meningococcal ACWY
    Engerix-B, Recombivax HB Pneumococcal conjugate (PCV) _ MenACWY
    dose (circle one): 0.5 mL 1.0 mL (Prevnar 13) (Menactra, Menveo)

    Heplisav-B (age 18 yrs and older) Pneumococcal polysaccharide Meningococcal B


    (PPSV) (Pneumovax 23) Bexsero
    DTaP (age 6 yrs and younger)
    Rotavirus Trumenba
    DTaP-HepB-IPV (Pediarix)
    RV1 (Rotarix) Influenza
    DTaP-IPV (Kinrix, Quadracel)
    RV5 (RotaTeq) brand
    DTaP-IPV/Hib (Pentacel)
    Human papillomavirus (HPV) dose (mL)
    DT (through age 6 yrs) (Gardasil 9)
    route (circle one): IM ID NAS
    Tdap (age 7 yrs and older) MMR Zoster (shingles)
    Td (age 7 yrs and older) Varicella (chickenpox) (Varivax) RZV (Shingrix, recombinant)
    Hib (monovalent) MMRV (ProQuad) ZVL (Zostavax, live)
    ActHIB Hepatitis A (Havrix; Vaqta) Other
    Hiberix dose (circle one): 0.5 mL 1.0 mL
    PedvaxHIB HepA-HepB (Twinrix)

    name of clinic providing services clinic contact person

    address email address

    city / state / zip phone

    Technical content reviewed by the Centers for Disease Control and Prevention

    Immunization Action Coalition Saint Paul, Minnesota • 651- 647- 9009 • www.immunize.org • www.vaccineinformation.org
    www.immunize.org/catg.d/p3060.pdf • Item #P3060 (5/18)

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