INFLUENZA VACCINE ADMINISTRATION RECORD

INFLUENZA VACCINE ADMINISTRATION RECORD
Your pharmacist will keep this record on file

I have read or have had explained to me written information about the vaccine listed below. I have had an opportunity to ask questions that were answered to my satisfaction. I understand the benefits and risks of the vaccine being administered and authorize the administration of the vaccine to me or to the person named below for whom I am authorized to make this decision. I understand that this information will be forwarded to my physician or primary care provider.”
Name:
as on Medicare or Insurance card)
Birthdate:

Month Day Year
Date
e mail:
example@example.com
Address:
City:
State:
Zip:
Telephone:
cell phone
Doctor:
Medicare #/ID #:
as on Medicare Card, including letters)
BIN (On Pharmacy Insurance Card)
PCN (On Pharmacy Insurance Card)
ID (On Pharmacy Insurance Card)
Group (On Pharmacy Insurance Card)
Plan and number - If Medicare Advantage Plan
Food/Drug Allergies:
Date:

Month Day Year
Date
Signature of person to receive the vaccine or person authorized to make the request (parent or guardian) and release this information to the patient’s physician or primary care provider:
Signature

Clear
Should be Empty: