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Get Immunize P3060 2012

Notification of Vaccination Letter Template Dear doctor or nurse at Patient s primary care clinic We recently provided vaccination services to one of your patients. 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 with a written record of the vaccination s given* We entered information about the vaccine s we administered in the regional immunization information system* Patient s name Patient s birthdate For a child parent s name The vaccine s we administered on Date is/are checked below. Vaccines G Hepatitis B Engerix-B Recombivax HB G Polio IPV G DTaP age 6 yrs and younger MMR DTaP-HepB-IPV Pediarix G Varicella Varivax DTaP-IPV MMRV ProQuad DTaP-IPV/Hib Hepatitis A Vaqta G through age 6 yrs DT HepA-HepB Human papillomavirus HPV G HPV2 Cervarix G HPV4 Tdap age 7 yrs and older G age 7 yrs and older Td Hib monovalent G G G PedvaxHIB Meningococcal conjugate MCV4 G MCV4-D G MCV4-CRM Menveo Hib-HepB Comvax Influenza Injectable standard dose Hib-MenCY MenHibrix Pneumococcal conjugate PCV13 Rotavirus G RV1 G RV5 Influenza Intranasal Zoster shingles Zostavax Other Name of clinic providing services Address City State Zip Contact person Email address Phone number Technical content reviewed by the Centers for Disease Control and Prevention www. immunize. org/catg. d/p3060. pdf Item P3060 12/12 Distributed by the Immunization Action Coalition 651 647-9009 www. 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 with a written record of the vaccination s given* We entered information about the vaccine s we administered in the regional immunization information system* Patient s name Patient s birthdate For a child parent s name The vaccine s we administered on Date is/are checked below. Please contact us if you have any questions about this information* We provided the patient or parent with a written record of the vaccination s given* We entered information about the vaccine s we administered in the regional immunization information system* Patient s name Patient s birthdate For a child parent s name The vaccine s we administered on Date is/are checked below. Vaccines G Hepatitis B Engerix-B Recombivax HB G Polio IPV G DTaP age 6 yrs and younger MMR DTaP-HepB-IPV Pediarix G Varicella Varivax DTaP-IPV MMRV ProQuad DTaP-IPV/Hib Hepatitis A Vaqta G through age 6 yrs DT HepA-HepB Human papillomavirus HPV G HPV2 Cervarix G HPV4 Tdap age 7 yrs and older G age 7 yrs and older Td Hib monovalent G G G PedvaxHIB Meningococcal conjugate MCV4 G MCV4-D G MCV4-CRM Menveo Hib-HepB Comvax Influenza Injectable standard dose Hib-MenCY MenHibrix Pneumococcal conjugate PCV13 Rotavirus G RV1 G RV5 Influenza Intranasal Zoster shingles Zostavax Other Name of clinic providing services Address City State Zip Contact person Email address Phone number Technical content reviewed by the Centers for Disease Control and Prevention www..

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