Notification Of Vaccination Letter Form PDF Details

In the interconnected world of healthcare, communication and collaboration among professionals are paramount to ensure quality patient care. A pivotal document facilitating this exchange of vital information is the Notification of Vaccination Letter. This template, designed to bridge gaps between vaccination service providers and primary care clinics, plays a crucial role in the comprehensive documentation of a patient's health records. When a patient receives a vaccine, this letter is sent to their doctor or nurse to inform them about the vaccine details, thereby enabling them to update the patient's medical records accurately. It includes essential information such as the patient's name and birthdate, the vaccines administered, the date of administration, dosages, and the administering clinic's contact details. By providing a written record to both the healthcare provider and the patient or their guardian, it ensures continuity of care and supports the integrity of the regional or state immunization information systems. Vaccines covered range from COVID-19 options like Moderna, Pfizer, and Janssen to a wide array of other vaccinations such as Hepatitis B, DTaP, Influenza, and many more, highlighting the form's versatility in catering to diverse patient needs. This streamlined communication tool not only supports healthcare providers in maintaining up-to-date patient records but also reinforces the collective endeavor to protect community health through effective immunization.

QuestionAnswer
Form NameNotification Of Vaccination Letter Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesnotification of vaccination letter, notification vaccination letter, immunize letter template, template vaccination template

Form Preview Example

Notification of Vaccination Letter Template

Dear doctor or nurse at

PATIENTS 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

COVID-19

mRNA (circle one): Moderna Pfizer

viral vector (Janssen [Johnson &

Johnson])

Hepatitis B

Engerix-B, Recombivax HB

DOSE (circle one): 0.5 mL 1.0 mL

Heplisav-B (age 18 yrs and older)

DTaP (age 6 yrs and younger)

DTaP-HepB-IPV (Pediarix)

DTaP-IPV (Kinrix, Quadracel)

DTaP-IPV/Hib (Pentacel)

DTaP-IPV-Hib-HepB (Vaxelis)

DT (through age 6 yrs)

Tdap (age 7 yrs and older)

Td (age 7 yrs and older)

Hib (monovalent)

ActHIB (PRP-T)

Hiberix (PRP-T)

PedvaxHIB (PRP-OMP)

Influenza

BRAND

DOSE (mL)

ROUTE (circle one): IM Nasal

IPV (Polio)

Pneumococcal conjugate (PCV13)

(Prevnar 13)

Pneumococcal polysaccharide (PPSV23) (Pneumovax 23)

Rotavirus

RV1 (Rotarix)

RV5 (RotaTeq)

Human papillomavirus (9vHPV)

(Gardasil 9)

MMR

Varicella (chickenpox) (Varivax)

MMRV (ProQuad)

Hepatitis A (Havrix; Vaqta)

DOSE (circle one): 0.5 mL 1.0 mL

HepA-HepB (Twinrix)

Meningococcal ACWY (MenACWY)

(circle one): (Menactra, MenQuadfi,

Menveo)

Meningococcal B (MenB)

Bexsero (MenB-4C)

Trumenba (MenB-FHbp)

Zoster (shingles) (RZV) (Shingrix)

Other

NAME OF CLINIC PROVIDING SERVICES

ADDRESS

CITY/STATE/ZIP

CLINIC CONTACT PERSON

EMAIL ADDRESS

PHONE

IMMUNIZATION ACTION COALITION Saint Paul, Minnesota 651-647-9009 www.immunize.org www.vaccineinformation.org

www.immunize.org/catg.d/p3060.pdf Item #P3060 (6/21)

How to Edit Notification Of Vaccination Letter Form Online for Free

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Step 1: Hit the "Get Form" button above on this page to access our editor.

Step 2: Using this state-of-the-art PDF editor, it's possible to accomplish more than merely fill out blank form fields. Express yourself and make your docs look high-quality with customized text put in, or optimize the file's original input to perfection - all comes with the capability to incorporate stunning photos and sign the PDF off.

This PDF requires specific details to be filled in, thus you should take the time to provide what is requested:

1. Begin completing the notification vaccination letter with a selection of necessary blanks. Gather all of the required information and make sure absolutely nothing is neglected!

vaccination template create completion process explained (step 1)

2. Once the previous segment is finished, you're ready include the necessary specifics in viral vector Janssen Johnson, Hiberix PRPT, MMR, Johnson, Hepatitis B, EngerixB Recombivax HB, dose circle one mL mL, HeplisavB age yrs and older, DTaP age yrs and younger, DTaPHepBIPV Pediarix, DTaPIPV Kinrix Quadracel, DTaPIPVHib Pentacel, DTaPIPVHibHepB Vaxelis, DT through age yrs, and Tdap age yrs and older allowing you to move forward further.

Filling in section 2 in vaccination template create

3. This subsequent segment should also be rather straightforward, address, citystatezip, email address, phone, Immunization Action Coalition, and wwwimmunizeorgcatgdppdf Item P - each one of these blanks will need to be filled in here.

Ways to fill out vaccination template create portion 3

Those who use this form often make mistakes while filling in email address in this part. Ensure you revise everything you type in right here.

Step 3: Check that the details are accurate and simply click "Done" to continue further. Create a free trial plan with us and get direct access to notification vaccination letter - available inside your personal account page. We do not share any details you use while dealing with documents at our website.