Injection Administration Form
Patient Information
Patient Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Other
Patient Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Staff Information
Administered by
First Name
Last Name
License number / employee ID
Pre-administration checks
Physician order verified
Patient identity confirmed
Allergy check completed
Consent obtained
Medication checked against MAR/order
Expiry date checked
Site assessed
Vitals before administration
Pregnancy status if applicable
Other
Medication/Injection Name
Dosage (mL)
Badge Number
Date of Injection
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Injection
Hour Minutes
AM
PM
AM/PM Option
Injection Site
Please Select
Left Arm
Right Arm
Left Thigh
Right Thigh
Belly
Other
Route of administration
Please Select
Intramuscular (IM)
Subcutaneous (SC / SubQ)
Intravenous (IV)
Intradermal (ID)
Other
Next Dose Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Staff Signature
Submit
Should be Empty: