Forms for Tracking Patient Immunizations

Keep track of your patients’ immunization information on these handy forms.

On this page:
Paper forms for health professionals
Online electronic reporting

Paper forms for health care providers

Forms for use in patients' medical chart:

Tip: Keep the immunization record forms in the front of medical charts so you remember to check immunizations at every visit.

  • Pediatric Immunization Record (PDF: 194KB/2 pages)
    Record the immunization given to your pediatric patients, including dose, lot number, manufacturer, VIS given, and site given. Also available as a sticker for the inside cover of the medical chart. To order stickers, call 800-657-3970 or 651-201-5503. Updated 3/13
  • Adult Immunization Record (PDF: 151KB/2 pages)
    Record the immunization given to your adult patients, including dose, lot number, manufacturer, VIS given, and site given. Also available as a sticker for the inside cover of the medical chart. To order stickers, call 800-657-3970 or 651-201-5503. Updated 3/13
  • Patient Immunization Record (PDF: 35KB/2 pages)
    Record the immunization given to your patients, including dose, lot number, manufacturer, VIS given, and site given. Use this one-size-fits-all form to record immunizations for infants, children, teens, and adults. Updated 3/13

Forms for use during vaccination clinics:

Note: Federal and Minnesota state law do not require signatures acknowledging receipt of VISs.

  • Adult Vaccine Administration Record
    Form used to record patient signatures during vaccination clinics. The form records the immunization given to adult patients including the dose, lot number, manufacturer, site given, VIS given, and signature of vaccinee or authorized representative. Also available in other languages.
  • Pediatric Vaccine Administration Record
    Form used to record patient signatures during vaccination clinics. The form records the immunization given to pediatric patients including the dose, lot number, manufacturer, site given, VIS given, and signature of vaccinee or authorized representative. Also available in other languages.

Online electronic reporting

Updated Wednesday, July 16, 2014 at 11:05AM