Notification Of Vaccination Letter Template
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1Notification 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
Pneumococcal
Human papillomavirus (HPV)
Hepatitis B
(Engerix-B; Recombivax HB)
dose
(circle one):
0.5 mL 1.0 mL
PCV13
HPV2
(Prevnar 13 [conjugate])
(Cervarix)
PPSV23
HPV4
DTaP
(Pneumovax 23 [poly-
(Gardasil)
(age 6 yrs and younger)
saccharide])
HPV9
(Gardasil 9)
DTaP-HepB-IPV
(Pediarix)
Rotavirus
Meningococcal
DTaP-IPV
(Kinrix, Quadracel)
RV1
(Rotarix)
MenACWY (MCV4)
DTaP-IPV/Hib
(Pentacel)
RV5
(RotaTeq)
(Menactra, Menveo
[conjugate])
DT
(through age 6 yrs)
MPSV4
(Menomune [polysaccharide])
IPV (Polio)
Tdap
(age 7 yrs and older)
MenB
(Bexsero, Trumenba [protein])
MMR
Td
(age 7 yrs and older)
Influenza
Varicella (chickenpox)
(Varivax)
brand
Hib
(monovalent)
MMRV
(ProQuad)
dose
ActHIB
(mL)
Hepatitis A
(Havrix; Vaqta)
route
Hiberix
IM
ID
NAS
(circle one):
dose
(circle one):
0.5 mL 1.0 mL
PedvaxHIB
Zoster (shingles)
(Zostavax)
HepA-HepB
(Twinrix)
Hib-HepB
Other
(Comvax)
Hib-MenCY
(MenHibrix)
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
651 - 647 - 9009
Saint Paul, Minnesota
•
•
•
/catg.d/p3060.pdf
Item #P3060 (6/16)
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Parent category: Letters