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Get Vaccine Immunization Record 2018-2024

Ient name Birthdate Before administering any vaccines, give the patient copies of all pertinent Vaccine Information Statements (VISs) and make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient s personal record card. Vaccine Type of Vaccine1 Date vaccine given (mo/day/yr) Funding Source (F,S,P)2 Route3 and Site3 Chart number practice name and address Vaccine Information Statement (VIS) Vaccine Lot # Mfr. Date on VIS4 Date given4.

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