Patient to Pharmacy Referral
Health care providers can download this template to refer appropriate patients to a pharmacy for vaccination.
Keep in mind, when using the pharmacy referral form:
- This form can also serve as an electronic prescription in some states.
- However, it is not designed to meet the prescription requirements in every state as these requirements vary. Please check the requirements in your state prior to utilizing this form as a prescription.
- After patient vaccination, the pharmacist may add the vaccine-specific information and fax it back to you enabling you to update your patient's record.
- State regulations regarding pharmacy vaccination differ, including whether a prescription is required. Check with the appropriate agency for the regulations in your state.