Vaccine Administration (Pharmacist Use ONLY)
I hereby certify that I have verified the screening questionnaire and consent with the above named patient
Vaccine: COVID-19 Vaccine Dose: 0.5ml Lot Number: Expire Date: Manufacture: Moderna
Injection Site: Left Arm / Right Arm Route: IM
VIS Identification: EUA COVID-19 VACCINE Date of Publication: 06/24/21
Did an Adverse Reaction occur? Yes No
Contacted VAERS 800-822-7967 Date/Time:
Primary Care Physician contacted: Yes No
Administered By: Pharmacist Signature: