Vaccine Appointment

Patient Name *

First

Last

Patient DOB: *

MM/DD/YYYY

Patient Ethnicity *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Patient verified in GRITS?

If answered "Yes" above write name and date verified below.

Date

Patient receiving which dose? *

Which vaccine is the patient receiving? *

Date of vaccine *

Which vaccine is the patient administered? *

What location was the vaccine administered?

Dose given?

Lot #:

Expiration Date of Vaccine?

Who administered the vaccine? *

First

Last

Was the Vaccine Information Sheet(VIS) information Given?

Time Vaccine Given

Time Observation Ends

Adverse Reactions? *

Add any comments above.

Observed by: *

First

Last

M.D. Whitest Medical Institute

401 15th St N
Cordele, GA 31015
(229) 469-8794