Pharmacy Immunization Service Delivery Form
Complete this checklist to document immunization service delivery and ensure all required steps are followed.
Patient Full Name
*
First Name
Last Name
Date of Immunization
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Vaccine Administered
*
Please Select
Influenza
COVID-19
Pneumococcal
Shingles (Herpes Zoster)
Tdap
Other
Vaccine Lot Number
*
Screening: Any contraindications to immunization today?
*
No contraindications
Yes, contraindications present
Consent obtained for immunization
*
Yes, verbal consent obtained
Yes, written consent obtained
No, consent not obtained (do not proceed)
Vaccine Administration Site
*
Left arm (deltoid)
Right arm (deltoid)
Thigh
Other
Route of Administration
*
Intramuscular (IM)
Subcutaneous (SC)
Intradermal (ID)
Nasal
Pharmacy Staff Initials
*
Follow-up Instructions Provided
*
Advised on possible side effects
Given aftercare leaflet
Told when to return for next dose (if applicable)
Submit
Should be Empty: