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Notification of Vaccination Letter Template: Vaccines Administered

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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Jacob Buck
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1K views1 page

Notification of Vaccination Letter Template: Vaccines Administered

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.

Uploaded by

Jacob Buck
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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