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Click ‘Get Form’ to open the Vaccine Consent and Administration Record in the editor.
Begin by filling out the Patient Information section. Enter the patient's last name, first name, date of birth, address, city, state, zip code, and phone number.
Provide details for the Primary Care Provider (PCP), including their name, phone number, address, and fax number.
In the vaccines section, check all vaccines that the patient is interested in receiving. Options include Flu, Shingles (Shingrix®), Tdap (Boostrix), Pneumonia Prevnar 13®, and Pneumonia Pneumovax® 23.
Answer the screening questions regarding current health status and allergies. Select 'Yes', 'No', or 'Don’t Know' as applicable.
If applicable, provide information about a caregiver or financially responsible party including their name, relationship to the patient, phone number, and address.
Review the consent for services statement carefully. Ensure that you understand it before signing and dating the form at the bottom.
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What are the eight details that must be documented when a vaccination is given?
Immunization providers are required by law to record what vaccine was given, the date the vaccine was given (month, day, year), the name of the manufacturer of the vaccine, the lot number, the signature and title of the person who gave the vaccine, and the address where the vaccine was given.
What should be documented after administering an injection?
Job Aid Date of administration. Vaccine manufacturer. Vaccine lot number. Name and title of the person who administered the vaccine and address of the facility where the permanent record will reside. Vaccine information statement (VIS) Date printed on the VIS. Date the VIS was given to the patient or parent/guardian.
Which vaccine is not documented under vaccination history?
Immunization providers may encounter persons who do not have documentation of the vaccines they have received. Providers should only accept written, dated records as evidence of vaccination, with the exception of influenza vaccine and pneumococcal polysaccharide vaccine (PPSV23).
What documentation is required when administering vaccines?
By law, the following information must be documented on the patients paper or electronic medical record (or on a permanent office log): The vaccine manufacturer. The lot number of the vaccine. The date the vaccine is administered.
What information must be documented regarding the administration of a vaccine Quizlet?
Federal law requires the following information to be documented after vaccine administration: All of the above: Vaccine lot number, vaccine manufacturer, date of administration, edition date of the vaccine information statement (VIS) provided to the patient or parent.
cvs vaccine administration form
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