Patient Referral to Pharmacy Template

Patient Referral to Pharmacy Template

Health care providers can download this template to refer appropriate patients to a pharmacy for vaccination.

Pharma Template

This form can also serve as an electronic prescription in some states. This form 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 vaccinating the patient, the pharmacist may add the vaccine-specific information and fax it back to you enabling you to update your patient's record.

Remember that state regulations regarding pharmacy vaccination differ, including whether a prescription is required. Check with the appropriate agency for the regulations in your state.

VACC-1114133-0003 12/16