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Dhec form 1103v 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the patient's name, date of birth, and ID number at the top of the form. This information is crucial for accurate record-keeping.
- For each vaccine administered, fill in the date given, injection site, manufacturer, lot number, and VIS date. Use our platform's text fields to ensure clarity.
- Circle the appropriate administration route (IM, SC, PO) for each vaccine using the editing tools available in our editor.
- In the Provider ID section, have the administering provider sign their name and add initials for future visits. This can be done electronically on our platform.
- Select the eligibility status from the provided table and enter the corresponding number for each vaccine administered.
- If applicable, check the box indicating a reliable history of Chickenpox and note the date checked.
- Document any allergies or comments in the designated section to provide comprehensive patient information.
- Finally, retain this completed form in the patient's medical record for future reference.
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dhec immunization records
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