Philadelphia kids immunization registry 2026

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The document is a Vaccine Administration Record from the Philadelphia Immunization Program, detailing the vaccines administered to patients, including their recommended ages, administration dates, sites, manufacturers, and lot numbers. It certifies that the appropriate Vaccine Information Statements were provided to patients or guardians at the time of immunization.

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Click ‘Get Form’ to open the Philadelphia Kids Immunization Registry in the editor.
Begin by entering the Provider Name and Address at the top of the form. This information is crucial for identifying where the immunizations are administered.
Fill in the Patient Name, Date of Birth, and Parent/Guardian details. Ensure accuracy as this information links to the child's immunization records.
In the Vaccine section, list each vaccine administered along with its Date Given, Site (e.g., Right Arm), Manufacturer, Lot Number, and VIS Publication Dates. Refer to the recommended ages for each vaccine to ensure compliance.
Finally, have the Vaccine Administrator sign in the designated area to certify that all necessary information was provided at the time of vaccination.

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