H.i.p. Immunization Shedule printable pdf download

H.i.p. Immunization Shedule

CHILD’S NAME: _____________________________

DOB: ______/______/________

H.I.P. IMMUNIZATION SCHEDULE

_____ We are following the CDC schedule for our child’s immunizations.

_____ We are following the Sears schedule for our child’s immunizations.

_____ We are following an Alternative schedule for our child’s immunizations. If selecting this option,

please ﬁll out the chart below and enter the age at which your child will receive the vaccine.

Place an X next to

Immunizations

Dose 1

Dose 2

Dose 3

Dose 4

Dose 5

the vaccines your

child will receive

DTaP (5 doses)

Hepatitis A (2 doses)

Hepatitis B (3 doses)

Haemophilus Inﬂuenza

Type B (4 doses)

Inactivated Polio Virus

(4 doses)

MMR (2 doses)

Pneumococcal (4 doses)

Rotavirus (3 doses)

Varicella (2 doses)

I understand that Highlands Integrative Pediatrics recommends the CDC’s routine immunization schedule. I have reviewed this plan

with my provider and understand that it is my responsibility to notify my provider in writing if there are any changes in this agreed

upon plan.

Parent Signature: _____________________________

Parent Name: ___________________________

Date: _____________

Parent Signature: _____________________________

Parent Name: ___________________________

Date: _____________

Provider Signature: ____________________________ Provider Name: __________________________

Date: _____________

H.i.p. Immunization Shedule