Notification Of Vaccination Letter Template
ADVERTISEMENT
1Notification of Vaccination Letter Template
Dear doctor or nurse at
:
Patient’s primary care clinic
We recently provided vaccination services to one of your patients. We want to make certain that you have infor-
mation 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) with a written record of the vaccination(s) given.
We entered information about the vaccine(s) we administered in the regional immunization
information system.
Patient’s name:
Patient’s birthdate:
(For a child, parent’s name:
Parent’s birthdate:
)
The vaccine(s) we administered on
is/are checked below.
Date
Vaccines
G Hepatitis B
G IPV (Polio)
(Engerix-B; Recombivax HB)
G DTaP
G MMR
(age 6 yrs and younger)
G DTaP-HepB-IPV
G Varicella
(Pediarix)
(Varivax)
MMRV
G
(ProQuad)
G DTaP-IPV
(Kinrix)
Hepatitis A
G
(Havrix; Vaqta)
G DTaP-IPV/Hib
(Pentacel)
HepA-HepB
G
(Twinrix)
G DT
(through age 6 yrs)
Human papillomavirus (HPV)
G Tdap
(age 7 yrs and older)
G
HPV2
(Cervarix)
G Td
(age 7 yrs and older)
G
HPV4
(Gardasil)
Hib (monovalent)
Meningococcal conjugate (MCV4)
G
ActHIB
G
MCV4-D
(Menactra)
G
Hiberix
G
MCV4-CRM
(Menveo)
G
PedvaxHIB
G Meningococcal polysaccharide (MPSV4)
G Hib-HepB
(Comvax)
G Influenza: Injectable, standard dose
G Hib-MenC
Y
(MenHibrix)
G Influenza: Injectable, high-dose
(Fluzone High-Dose)
G Pneumococcal conjugate (PCV13)
G Influenza: Intranasal
(FluMist)
G Pneumococcal polysaccharide (PPSV23)
G Influenza: Intradermal
(Fluzone Intradermal)
Rotavirus
G Zoster (shingles)
(Zostavax)
G
RV1
(Rotarix)
G Other
G
RV5
(RotaTeq)
Name of clinic providing services
Address
City, State, Zip
Contact person
Email address
Phone number
• Item #P3060 (12/12)
Technical content reviewed by the Centers for Disease Control and Prevention
Distributed by the Immunization Action Coalition • (651) 647-9009 • • •
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical